Sample Type / Medical Specialty: Hematology - Oncology
Sample Name: 3-Dimensional Simulation
Description: 3-Dimensional Simulation. This patient is
undergoing 3-dimensionally planned radiation therapy in order to adequately
target structures at risk while diminishing the degree of exposure to
uninvolved adjacent normal structures.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
3-DIMENSIONAL SIMULATION
This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. Radiographs are taken and these films are approved by the physician. Appropriate marks are placed on the patient's skin or on the immobilization device.
The patient is transferred to the diagnostic facility and placed on a flat CT scan table. Scans are performed through the targeted area. The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images. The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. Appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.
Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.
In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.
This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. Radiographs are taken and these films are approved by the physician. Appropriate marks are placed on the patient's skin or on the immobilization device.
The patient is transferred to the diagnostic facility and placed on a flat CT scan table. Scans are performed through the targeted area. The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images. The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. Appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.
Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.
In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.
Sample Type / Medical Specialty: Hematology - Oncology
Sample Name: Adrenalectomy & Umbilical Hernia Repair
Sample Name: Adrenalectomy & Umbilical Hernia Repair
Description: Laparoscopic hand-assisted left adrenalectomy
and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass
in his right adrenal.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES
1. Adrenal mass, right sided.
2. Umbilical hernia.
POSTOPERATIVE DIAGNOSES
1. Adrenal mass, right sided.
2. Umbilical hernia.
OPERATION PERFORMED: Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.
ANESTHESIA: General.
CLINICAL NOTE: This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. Alternative of fully laparoscopic are open surgery or watching the lesion.
DESCRIPTION OF OPERATION: In the right flank-up position, table was flexed. He had a Foley catheter in place. Incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed to this.
The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. The vena cava was identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. Specimen was placed in a collection bag, removed intact.
Hemostasis was excellent.
The umbilical hernia had been completely taken down. The edges were freshened up. Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.
Skin closed with clips.
He tolerated the procedure well. All sponge and instrument counts were correct. Estimated blood loss less than 100 mL.
The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
1. Adrenal mass, right sided.
2. Umbilical hernia.
POSTOPERATIVE DIAGNOSES
1. Adrenal mass, right sided.
2. Umbilical hernia.
OPERATION PERFORMED: Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.
ANESTHESIA: General.
CLINICAL NOTE: This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. Alternative of fully laparoscopic are open surgery or watching the lesion.
DESCRIPTION OF OPERATION: In the right flank-up position, table was flexed. He had a Foley catheter in place. Incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed to this.
The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. The vena cava was identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. Specimen was placed in a collection bag, removed intact.
Hemostasis was excellent.
The umbilical hernia had been completely taken down. The edges were freshened up. Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.
Skin closed with clips.
He tolerated the procedure well. All sponge and instrument counts were correct. Estimated blood loss less than 100 mL.
The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
Sample Type / Medical Specialty: Hematology - Oncology
Sample Name: Anaplastic Astrocytoma - Letter
Sample Name: Anaplastic Astrocytoma - Letter
Description: Patient seen in Neuro-Oncology Clinic because
of increasing questions about what to do next for his anaplastic astrocytoma.
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Month DD, YYYY
XYZ
RE: ABC
MEDICAL RECORD#: 123
Dear Dr. XYZ:
I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.
Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.
After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.
From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.
Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.
While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.
I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.
Sincerely,
XYZ
RE: ABC
MEDICAL RECORD#: 123
Dear Dr. XYZ:
I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.
Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.
After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.
From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.
Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.
While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.
I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.
Sincerely,
Sample Name: Anemia - Consult
Description: Refractory anemia that is transfusion
dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1
and requiring transfusion.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
DIAGNOSIS: Refractory anemia that is transfusion dependent.
CHIEF COMPLAINT: I needed a blood transfusion.
HISTORY: The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.
PAST MEDICAL HISTORY: Diabetes.
PAST SURGICAL HISTORY: Hernia repair.
ALLERGIES: He has no allergies.
MEDICATIONS: Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.
SOCIAL HISTORY: He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.
FAMILY HISTORY: Negative for blood or cancer disorders according to the patient.
PHYSICAL EXAMINATION:
GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.
VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.
HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.
NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.
CHEST: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.
EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.
NEUROLOGIC: Noncontributory.
DERMATOLOGIC: Noncontributory.
CARDIOVASCULAR: Noncontributory.
IMPRESSION: At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.
RECOMMENDATIONS: At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.
As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.
CHIEF COMPLAINT: I needed a blood transfusion.
HISTORY: The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.
PAST MEDICAL HISTORY: Diabetes.
PAST SURGICAL HISTORY: Hernia repair.
ALLERGIES: He has no allergies.
MEDICATIONS: Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.
SOCIAL HISTORY: He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.
FAMILY HISTORY: Negative for blood or cancer disorders according to the patient.
PHYSICAL EXAMINATION:
GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.
VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.
HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.
NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.
CHEST: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.
EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.
NEUROLOGIC: Noncontributory.
DERMATOLOGIC: Noncontributory.
CARDIOVASCULAR: Noncontributory.
IMPRESSION: At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.
RECOMMENDATIONS: At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.
As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.
Sample Name: Anemia & Leukemia Followup
Description: Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.
(Medical Transcription Sample Report)
CHIEF COMPLAINT:
1. Chronic lymphocytic leukemia (CLL).
2. Autoimmune hemolytic anemia.
3. Oral ulcer.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial.
CURRENT MEDICATIONS: Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.
ALLERGIES: Vicodin.
REVIEW OF SYSTEMS: The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 120/74. HEART RATE: 72. TEMP: 97.8. Weight: 112.7 kg.
GEN: He has a obvious cold sore on his bottom lip on the left.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. His oropharynx is notable for ulcer on his tongue. No ulcers on his buccal mucosa.
NECK: Supple. He has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
LABORATORY DATA: His white blood cell count is 4.6, hemoglobin 14.2, hematocrit 42, and platelets 207,000.
ASSESSMENT/PLAN: This is a 72-year-old gentleman with chronic lymphocytic leukemia on chronic steroids for autoimmune hemolytic anemia. His blood counts are relatively stable at 5 mg of prednisone every other day. We will plan on putting him back on the Valtrex and decreasing his steroids to 1 mg daily. I will see him back in clinic in a week.
1. Chronic lymphocytic leukemia (CLL).
2. Autoimmune hemolytic anemia.
3. Oral ulcer.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial.
CURRENT MEDICATIONS: Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.
ALLERGIES: Vicodin.
REVIEW OF SYSTEMS: The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 120/74. HEART RATE: 72. TEMP: 97.8. Weight: 112.7 kg.
GEN: He has a obvious cold sore on his bottom lip on the left.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. His oropharynx is notable for ulcer on his tongue. No ulcers on his buccal mucosa.
NECK: Supple. He has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
LABORATORY DATA: His white blood cell count is 4.6, hemoglobin 14.2, hematocrit 42, and platelets 207,000.
ASSESSMENT/PLAN: This is a 72-year-old gentleman with chronic lymphocytic leukemia on chronic steroids for autoimmune hemolytic anemia. His blood counts are relatively stable at 5 mg of prednisone every other day. We will plan on putting him back on the Valtrex and decreasing his steroids to 1 mg daily. I will see him back in clinic in a week.
Sample Name:
Aplastic Anemia Followup
Description: Aplastic anemia. After several bone marrow biopsies, she was
diagnosed with aplastic anemia. She started cyclosporine and prednisone.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Aplastic anemia.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.
Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.
CURRENT MEDICATIONS: Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. Hypertension.
2. GERD.
3. Osteoarthritis.
4. Status post tonsillectomy.
5. Status post hysterectomy.
6. Status post bilateral cataract surgery.
7. Esophageal stricture status post dilatation approximately four times.
SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.
FAMILY HISTORY: Her sister had breast cancer.
PHYSICAL EXAM:
VIT: Height 167 cm, weight 66 kg, blood pressure 122/70, pulse 84, and temperature is 98.9.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Aplastic anemia. I am going to repeat her CMP today to assess her kidney function. It is possible that I may resume the cyclosporine, but at 50% dose reduction. She was supratherapeutic when her cyclosporine level was drawn in the hospital. Her values were 555 and the trough should be 100 to 400. We will continue with monthly CBCs for now and I will see her again in one month.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.
Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.
CURRENT MEDICATIONS: Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. Hypertension.
2. GERD.
3. Osteoarthritis.
4. Status post tonsillectomy.
5. Status post hysterectomy.
6. Status post bilateral cataract surgery.
7. Esophageal stricture status post dilatation approximately four times.
SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.
FAMILY HISTORY: Her sister had breast cancer.
PHYSICAL EXAM:
VIT: Height 167 cm, weight 66 kg, blood pressure 122/70, pulse 84, and temperature is 98.9.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Aplastic anemia. I am going to repeat her CMP today to assess her kidney function. It is possible that I may resume the cyclosporine, but at 50% dose reduction. She was supratherapeutic when her cyclosporine level was drawn in the hospital. Her values were 555 and the trough should be 100 to 400. We will continue with monthly CBCs for now and I will see her again in one month.
Sample Name:
Axillary Dissection & Mass Excision
Description: Left axillary dissection with incision and drainage of left
axillary mass. Right axillary mass excision and incision and drainage.
Bilateral axillary masses, rule out recurrent Hodgkin's disease.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Bilateral axillary masses, rule out recurrent Hodgkin's
disease.
POSTOPERATIVE DIAGNOSIS: Bilateral axillary masses, rule out recurrent Hodgkin's disease.
PROCEDURE PERFORMED:
1. Left axillary dissection with incision and drainage of left axillary mass.
2. Right axillary mass excision and incision and drainage.
ANESTHESIA: LMA.
SPECIMENS: Left axillary mass with nodes and right axillary mass.
ESTIMATED BLOOD LOSS: Less than 30 cc.
INDICATION: This 56-year-old male presents to surgical office with history of bilateral axillary masses. Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter. The patient had been continued on antibiotics preoperatively. The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time. Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses. The patient was explained the risks and benefits of the procedure and informed consent was obtained.
GROSS FINDINGS: Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.
No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time. The right axillary mass was excised without difficulty without requiring full axillary dissection.
PROCEDURE: The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete. A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass. Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis. Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature. Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture. Upon revaluation of the incisional site, it was noted to be hemostatic. Warm lap sponge was then left in place at this site. Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction. This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation. This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch. Steri-Strips were applied. Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision. This was placed within the incision site, ________ drainage of the axillary potential space. Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique. Steri-Strips and sterile dressings were applied. JP bulb was then placed to suction and sterile dressings were applied to both axilla. The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition. He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.
POSTOPERATIVE DIAGNOSIS: Bilateral axillary masses, rule out recurrent Hodgkin's disease.
PROCEDURE PERFORMED:
1. Left axillary dissection with incision and drainage of left axillary mass.
2. Right axillary mass excision and incision and drainage.
ANESTHESIA: LMA.
SPECIMENS: Left axillary mass with nodes and right axillary mass.
ESTIMATED BLOOD LOSS: Less than 30 cc.
INDICATION: This 56-year-old male presents to surgical office with history of bilateral axillary masses. Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter. The patient had been continued on antibiotics preoperatively. The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time. Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses. The patient was explained the risks and benefits of the procedure and informed consent was obtained.
GROSS FINDINGS: Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.
No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time. The right axillary mass was excised without difficulty without requiring full axillary dissection.
PROCEDURE: The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete. A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass. Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis. Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature. Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture. Upon revaluation of the incisional site, it was noted to be hemostatic. Warm lap sponge was then left in place at this site. Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction. This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation. This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch. Steri-Strips were applied. Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision. This was placed within the incision site, ________ drainage of the axillary potential space. Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique. Steri-Strips and sterile dressings were applied. JP bulb was then placed to suction and sterile dressings were applied to both axilla. The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition. He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.
Sample Name:
BCCa Excision - Canthus
Description: Excision basal cell carcinoma, right medial canthus with
frozen section, and reconstruction of defect with glabellar rotation flap.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (0.8 cm diameter), right medial canthus.
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma (0.8 cm diameter), right medial canthus.
OPERATION: Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.
ANESTHESIA: Monitored anesthesia care.
JUSTIFICATION: The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus. She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.
PROCEDURE: With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table. The face was prepped with pHisoHex draped. The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.
Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology. The report was "basal cell carcinoma with all margins free of tumor." Hemostasis was controlled with the Bovie. Excised lesion diameter was 1.2 cm. The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin. The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin. Donor site was closed in V-Y fashion with similar suture technique.
The wounds were dressed with bacitracin ointment. The patient was returned to the recovery room in satisfactory condition. She tolerated the procedure satisfactorily, and then no complications. Blood loss was essentially nil.
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma (0.8 cm diameter), right medial canthus.
OPERATION: Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.
ANESTHESIA: Monitored anesthesia care.
JUSTIFICATION: The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus. She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.
PROCEDURE: With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table. The face was prepped with pHisoHex draped. The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.
Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology. The report was "basal cell carcinoma with all margins free of tumor." Hemostasis was controlled with the Bovie. Excised lesion diameter was 1.2 cm. The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin. The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin. Donor site was closed in V-Y fashion with similar suture technique.
The wounds were dressed with bacitracin ointment. The patient was returned to the recovery room in satisfactory condition. She tolerated the procedure satisfactorily, and then no complications. Blood loss was essentially nil.
Sample Name:
BCCa Excision - Cheek
Description: Excision of basal cell carcinoma. Closure complex, open
wound. Bilateral capsulectomies. Bilateral explantation and removal of ruptured
silicone gel implants
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES
1. Basal cell carcinoma, right cheek.
2. Basal cell carcinoma, left cheek.
3. Bilateral ruptured silicone gel implants.
4. Bilateral Baker grade IV capsular contracture.
5. Breast ptosis.
POSTOPERATIVE DIAGNOSES
1. Basal cell carcinoma, right cheek.
2. Basal cell carcinoma, left cheek.
3. Bilateral ruptured silicone gel implants.
4. Bilateral Baker grade IV capsular contracture.
5. Breast ptosis.
PROCEDURE
1. Excision of basal cell carcinoma, right cheek, 2.7 cm x 1.5 cm.
2. Excision of basal cell carcinoma, left cheek, 2.3 x 1.5 cm.
3. Closure complex, open wound utilizing local tissue advancement flap, right cheek.
4. Closure complex, open wound, left cheek utilizing local tissue advancement flap.
5. Bilateral explantation and removal of ruptured silicone gel implants.
6. Bilateral capsulectomies.
7. Replacement with bilateral silicone gel implants, 325 cc.
INDICATIONS FOR PROCEDURES
The patient is a 61-year-old woman who presents with a history of biopsy-proven basal cell carcinoma, right and left cheek. She had no prior history of skin cancer. She is status post bilateral cosmetic breast augmentation many years ago and the records are not available for this procedure. She has noted progressive hardening and distortion of the implant. She desires to have the implants removed, capsulectomy and replacement of implants. She would like to go slightly smaller than her current size as she has ptosis going with a smaller implant combined with capsulectomy will result in worsening of her ptosis. She may require a lift. She is not consenting to lift due to the surgical scars.
PAST MEDICAL HISTORY
Significant for deep venous thrombosis and acid reflux.
PAST SURGICAL HISTORY
Significant for appendectomy, colonoscopy and BAM.
MEDICATIONS
1. Coumadin. She stopped her Coumadin five days prior to the procedures.
2. Lipitor
3. Effexor.
4. Klonopin.
ALLERGIES
None.
REVIEW OF SYSTEMS
Negative for dyspnea on exertion, palpitations, chest pain, and phlebitis.
PHYSICAL EXAMINATION
VITAL SIGNS: Height 5'8", weight 155 pounds.
FACE: Examination of the face demonstrates basal cell carcinoma, right and left cheek. No lesions are noted in the regional lymph node base and no mass is appreciated.
BREAST: Examination of the breast demonstrates bilateral grade IV capsular contracture. She has asymmetry in distortion of the breast. No masses are appreciated in the breast or the axilla. The implants appear to be subglandular.
CHEST: Clear to auscultation and percussion.
CARDIOVASCULAR: Regular rate and rhythm.
EXTREMITIES: Show full range of motion. No clubbing, cyanosis or edema.
SKIN: Significant environmental actinic skin damage.
I recommended excision of basal cell cancers with frozen section control of the margin, closure will require local tissue flaps. I recommended exchange of the implants with reaugmentation. No final size is guaranteed or implied. We will decrease the size of the implants based on the intraoperative findings as the size is not known. Several options are available. Sizer implants will be placed to best estimate postoperative size. Ptosis will be worse following capsulectomy and going with a smaller implant. She may require a lift in the future. We have obtained preoperative clearance from the patient's cardiologist, Dr. K. The patient has been taken off Coumadin for five days and will be placed back on Coumadin the day after the surgery. The risk of deep venous thrombosis is discussed. Other risk including bleeding, infection, allergic reaction, pain, scarring, hypertrophic scarring and poor cosmetic resolve, worsening of ptosis, exposure, extrusion, the rupture of the implants, numbness of the nipple-areolar complex, hematoma, need for additional surgery, recurrent capsular contracture and recurrence of the skin cancer was all discussed, which she understands and informed consent is obtained.
PROCEDURE IN DETAIL
After appropriate informed consent was obtained, the patient was placed in the preoperative holding area with **** input. She was then taken to the major operating room with ABCD Surgery Center, placed in a supine position. Intravenous antibiotics were given. TED hose and SCDs were placed. After the induction of adequate general endotracheal anesthesia, she was prepped and draped in the usual sterile fashion. Sites for excision and skin cancers were carefully marked with 5 mm margin. These were injected with 1% lidocaine with epinephrine.
After allowing adequate time for basal constriction hemostasis, excision was performed, full thickness of the skin. They were tagged at the 12 o'clock position and sent for frozen section. Hemostasis was achieved using electrocautery. Once margins were determined to be free of involvement, local tissue flaps were designed for advancement. Undermining was performed. Hemostasis was achieved using electrocautery. Closure was performed under moderate tension with interrupted 5-0 Vicryl. Skin was closed under loop magnification paying meticulous attention and cosmetic details with 6-0 Prolene. Attention was then turned to the breast, clothes were changed, gloves were changed, incision was planned and the previous inframammary incision beginning on the right incision was made. Dissection was carried down to the capsule. It was extremely calcified. Dissection of the anterior surface of the capsule was performed. The implant was subglandular, the capsule was entered, implant was noted to be grossly intact; however, there was free silicone. Implant was removed and noted to be ruptured. No marking as to the size of the implant was found.
Capsulectomy was performed leaving a small portion in the axilla in the inframammary fold. Pocket was modified to medialize the implant by placing 2-0 Prolene laterally in mattress sutures to restrict the pocket. In identical fashion, capsulectomy was performed on the left. Implant was noted to be grossly ruptured. No marking was found for the size of the implant. The entire content was weighed and found to be 350 grams. Right side was weighed and noted to be 338 grams, although some silicone was lost in the transfer and most likely was identical 350 grams. The implants appeared to be double lumen with the saline portion deflated. Completion of the capsulectomy was performed on the left.
The pocket was again fashioned to improve symmetry with the right with Prolene. Pockets were thoroughly irrigated. Hemostasis was achieved using electrocautery, checked for symmetry, which is determined to be excellent. Several liters of normal saline were utilized to irrigate the pocket. Hemostasis was determined to be excellent. Drains were placed. 2-0 Vicryl sutures were preplaced. Pockets were checked for hemostasis, irrigated with normal saline, sizing was performed with placement of 275 cc implants. She was placed in a sitting position. This significantly worsened ptosis and for this reason, 325 cc implants were chosen. She is placed back in a supine position. Pockets were irrigated with antibiotic solution, 2-0 Vicryl sutures were preplaced and gloves were changed. The patient was reprepped with Betadine, towels were changed.
These were soaked in antibiotic solution. Gloves were changed, gowns were changed, the patient was reprepped, towels were changed and implants were placed. The patient was placed in a sitting position. Symmetry was excellent. There was noted to be a decrease of volume of approximately 40 cc from the capsulectomy as well as the additional reduction of 25 cc. Ptosis was slightly worse; however, excellent shape of the breast. She was placed back in a supine position, preplaced 2-0 Vicryl sutures were tied; a second layer subcutaneous of 3-0 Vicryl was placed followed by a third of 4-0 Vicryl. The skin was closed with a running 4-0 Prolene. Drains were secured. All sponge and needle counts were correct. Dressing was applied.
COMPLICATIONS
None.
DISPOSITION
To recovery room.
1. Basal cell carcinoma, right cheek.
2. Basal cell carcinoma, left cheek.
3. Bilateral ruptured silicone gel implants.
4. Bilateral Baker grade IV capsular contracture.
5. Breast ptosis.
POSTOPERATIVE DIAGNOSES
1. Basal cell carcinoma, right cheek.
2. Basal cell carcinoma, left cheek.
3. Bilateral ruptured silicone gel implants.
4. Bilateral Baker grade IV capsular contracture.
5. Breast ptosis.
PROCEDURE
1. Excision of basal cell carcinoma, right cheek, 2.7 cm x 1.5 cm.
2. Excision of basal cell carcinoma, left cheek, 2.3 x 1.5 cm.
3. Closure complex, open wound utilizing local tissue advancement flap, right cheek.
4. Closure complex, open wound, left cheek utilizing local tissue advancement flap.
5. Bilateral explantation and removal of ruptured silicone gel implants.
6. Bilateral capsulectomies.
7. Replacement with bilateral silicone gel implants, 325 cc.
INDICATIONS FOR PROCEDURES
The patient is a 61-year-old woman who presents with a history of biopsy-proven basal cell carcinoma, right and left cheek. She had no prior history of skin cancer. She is status post bilateral cosmetic breast augmentation many years ago and the records are not available for this procedure. She has noted progressive hardening and distortion of the implant. She desires to have the implants removed, capsulectomy and replacement of implants. She would like to go slightly smaller than her current size as she has ptosis going with a smaller implant combined with capsulectomy will result in worsening of her ptosis. She may require a lift. She is not consenting to lift due to the surgical scars.
PAST MEDICAL HISTORY
Significant for deep venous thrombosis and acid reflux.
PAST SURGICAL HISTORY
Significant for appendectomy, colonoscopy and BAM.
MEDICATIONS
1. Coumadin. She stopped her Coumadin five days prior to the procedures.
2. Lipitor
3. Effexor.
4. Klonopin.
ALLERGIES
None.
REVIEW OF SYSTEMS
Negative for dyspnea on exertion, palpitations, chest pain, and phlebitis.
PHYSICAL EXAMINATION
VITAL SIGNS: Height 5'8", weight 155 pounds.
FACE: Examination of the face demonstrates basal cell carcinoma, right and left cheek. No lesions are noted in the regional lymph node base and no mass is appreciated.
BREAST: Examination of the breast demonstrates bilateral grade IV capsular contracture. She has asymmetry in distortion of the breast. No masses are appreciated in the breast or the axilla. The implants appear to be subglandular.
CHEST: Clear to auscultation and percussion.
CARDIOVASCULAR: Regular rate and rhythm.
EXTREMITIES: Show full range of motion. No clubbing, cyanosis or edema.
SKIN: Significant environmental actinic skin damage.
I recommended excision of basal cell cancers with frozen section control of the margin, closure will require local tissue flaps. I recommended exchange of the implants with reaugmentation. No final size is guaranteed or implied. We will decrease the size of the implants based on the intraoperative findings as the size is not known. Several options are available. Sizer implants will be placed to best estimate postoperative size. Ptosis will be worse following capsulectomy and going with a smaller implant. She may require a lift in the future. We have obtained preoperative clearance from the patient's cardiologist, Dr. K. The patient has been taken off Coumadin for five days and will be placed back on Coumadin the day after the surgery. The risk of deep venous thrombosis is discussed. Other risk including bleeding, infection, allergic reaction, pain, scarring, hypertrophic scarring and poor cosmetic resolve, worsening of ptosis, exposure, extrusion, the rupture of the implants, numbness of the nipple-areolar complex, hematoma, need for additional surgery, recurrent capsular contracture and recurrence of the skin cancer was all discussed, which she understands and informed consent is obtained.
PROCEDURE IN DETAIL
After appropriate informed consent was obtained, the patient was placed in the preoperative holding area with **** input. She was then taken to the major operating room with ABCD Surgery Center, placed in a supine position. Intravenous antibiotics were given. TED hose and SCDs were placed. After the induction of adequate general endotracheal anesthesia, she was prepped and draped in the usual sterile fashion. Sites for excision and skin cancers were carefully marked with 5 mm margin. These were injected with 1% lidocaine with epinephrine.
After allowing adequate time for basal constriction hemostasis, excision was performed, full thickness of the skin. They were tagged at the 12 o'clock position and sent for frozen section. Hemostasis was achieved using electrocautery. Once margins were determined to be free of involvement, local tissue flaps were designed for advancement. Undermining was performed. Hemostasis was achieved using electrocautery. Closure was performed under moderate tension with interrupted 5-0 Vicryl. Skin was closed under loop magnification paying meticulous attention and cosmetic details with 6-0 Prolene. Attention was then turned to the breast, clothes were changed, gloves were changed, incision was planned and the previous inframammary incision beginning on the right incision was made. Dissection was carried down to the capsule. It was extremely calcified. Dissection of the anterior surface of the capsule was performed. The implant was subglandular, the capsule was entered, implant was noted to be grossly intact; however, there was free silicone. Implant was removed and noted to be ruptured. No marking as to the size of the implant was found.
Capsulectomy was performed leaving a small portion in the axilla in the inframammary fold. Pocket was modified to medialize the implant by placing 2-0 Prolene laterally in mattress sutures to restrict the pocket. In identical fashion, capsulectomy was performed on the left. Implant was noted to be grossly ruptured. No marking was found for the size of the implant. The entire content was weighed and found to be 350 grams. Right side was weighed and noted to be 338 grams, although some silicone was lost in the transfer and most likely was identical 350 grams. The implants appeared to be double lumen with the saline portion deflated. Completion of the capsulectomy was performed on the left.
The pocket was again fashioned to improve symmetry with the right with Prolene. Pockets were thoroughly irrigated. Hemostasis was achieved using electrocautery, checked for symmetry, which is determined to be excellent. Several liters of normal saline were utilized to irrigate the pocket. Hemostasis was determined to be excellent. Drains were placed. 2-0 Vicryl sutures were preplaced. Pockets were checked for hemostasis, irrigated with normal saline, sizing was performed with placement of 275 cc implants. She was placed in a sitting position. This significantly worsened ptosis and for this reason, 325 cc implants were chosen. She is placed back in a supine position. Pockets were irrigated with antibiotic solution, 2-0 Vicryl sutures were preplaced and gloves were changed. The patient was reprepped with Betadine, towels were changed.
These were soaked in antibiotic solution. Gloves were changed, gowns were changed, the patient was reprepped, towels were changed and implants were placed. The patient was placed in a sitting position. Symmetry was excellent. There was noted to be a decrease of volume of approximately 40 cc from the capsulectomy as well as the additional reduction of 25 cc. Ptosis was slightly worse; however, excellent shape of the breast. She was placed back in a supine position, preplaced 2-0 Vicryl sutures were tied; a second layer subcutaneous of 3-0 Vicryl was placed followed by a third of 4-0 Vicryl. The skin was closed with a running 4-0 Prolene. Drains were secured. All sponge and needle counts were correct. Dressing was applied.
COMPLICATIONS
None.
DISPOSITION
To recovery room.
Sample Name:
BCCa Excision - Lower Lid
Description: Excision of large basal cell carcinoma, right lower lid, and
repaired with used dorsal conjunctival flap in the upper lid and a large
preauricular skin graft.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Extremely large basal cell carcinoma, right lower lid.
POSTOPERATIVE DIAGNOSIS: Extremely large basal cell carcinoma, right lower lid.
TITLE OF OPERATION: Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.
PROCEDURE: The patient was brought into the operating room and prepped and draped in usual fashion. Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid. A frontal nerve block was also given on the right upper lid. The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect. The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.
The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly. The specimen was then marked and sent to pathology for frozen section. Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid. The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis. Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly. It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.
The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region. The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures. The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.
Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied. The patient tolerated the procedure well and was sent to recovery room in good condition.
POSTOPERATIVE DIAGNOSIS: Extremely large basal cell carcinoma, right lower lid.
TITLE OF OPERATION: Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.
PROCEDURE: The patient was brought into the operating room and prepped and draped in usual fashion. Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid. A frontal nerve block was also given on the right upper lid. The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect. The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.
The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly. The specimen was then marked and sent to pathology for frozen section. Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid. The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis. Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly. It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.
The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region. The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures. The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.
Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied. The patient tolerated the procedure well and was sent to recovery room in good condition.
Sample Name:
BCCa Excision - Nasal Tip
Description: Excision of nasal tip basal carcinoma, previous positive
biopsy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma, nasal tip, previous positive biopsy.
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma, nasal tip, previous positive biopsy.
OPERATION PERFORMED: Excision of nasal tip basal carcinoma. Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.
INDICATION: A 66-year-old female for excision of nasal basal cell carcinoma. This area is to be excised accordingly and closed. We had multiple discussions regarding types of closure.
SUMMARY: The patient was brought to the OR in satisfactory condition and placed supine on the OR table. Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision. The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.
The specimen was sent to pathology. Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly. Final margins were clear.
Closure consisted of undermining circumferentially. Advancement closure with dog ear removal distally and proximally was accomplished without difficulty. Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.
The patient is discharged on minocycline and Darvocet-N 100.
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma, nasal tip, previous positive biopsy.
OPERATION PERFORMED: Excision of nasal tip basal carcinoma. Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.
INDICATION: A 66-year-old female for excision of nasal basal cell carcinoma. This area is to be excised accordingly and closed. We had multiple discussions regarding types of closure.
SUMMARY: The patient was brought to the OR in satisfactory condition and placed supine on the OR table. Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision. The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.
The specimen was sent to pathology. Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly. Final margins were clear.
Closure consisted of undermining circumferentially. Advancement closure with dog ear removal distally and proximally was accomplished without difficulty. Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.
The patient is discharged on minocycline and Darvocet-N 100.
Sample Name:
Biopsy - Axillary Lymph Node
Description: Right axillary adenopathy, thrombocytopenia, and
hepatosplenomegaly. Right axillary lymph node biopsy.
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PREOPERATIVE DIAGNOSES:
1. Right axillary adenopathy.
2. Thrombocytopenia.
3. Hepatosplenomegaly.
POSTOPERATIVE DIAGNOSES:
1. Right axillary adenopathy.
2. Thrombocytopenia.
3. Hepatosplenomegaly.
PROCEDURE PERFORMED: Right axillary lymph node biopsy.
ANESTHESIA: Local with sedation.
COMPLICATIONS: None.
DISPOSITION: The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
BRIEF HISTORY: The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly. The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis. Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.
INTRAOPERATIVE FINDINGS: The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.
PROCEDURE: After informed written consent, risks and benefits of this procedure were explained to the patient. The patient was brought to the operating suite, prepped and draped in a normal sterile fashion. Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed. First, the skin was anesthetized with 1% lidocaine solution. Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla. Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node. The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab. Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained. Next the deep dermal layers were approximated with #3-0 Vicryl suture. After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending. The patient did tolerated the procedure well. Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.
1. Right axillary adenopathy.
2. Thrombocytopenia.
3. Hepatosplenomegaly.
POSTOPERATIVE DIAGNOSES:
1. Right axillary adenopathy.
2. Thrombocytopenia.
3. Hepatosplenomegaly.
PROCEDURE PERFORMED: Right axillary lymph node biopsy.
ANESTHESIA: Local with sedation.
COMPLICATIONS: None.
DISPOSITION: The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
BRIEF HISTORY: The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly. The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis. Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.
INTRAOPERATIVE FINDINGS: The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.
PROCEDURE: After informed written consent, risks and benefits of this procedure were explained to the patient. The patient was brought to the operating suite, prepped and draped in a normal sterile fashion. Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed. First, the skin was anesthetized with 1% lidocaine solution. Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla. Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node. The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab. Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained. Next the deep dermal layers were approximated with #3-0 Vicryl suture. After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending. The patient did tolerated the procedure well. Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.
Sample Name:
Biopsy - Cervical Lymph Node
Description: Excisional biopsy of right cervical lymph node.
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PREOPERATIVE DIAGNOSIS: Cervical lymphadenopathy.
POSTOPERATIVE DIAGNOSIS: Cervical lymphadenopathy.
PROCEDURE: Excisional biopsy of right cervical lymph node.
ANESTHESIA: General endotracheal anesthesia.
SPECIMEN: Right cervical lymph node.
EBL: 10 cc.
COMPLICATIONS: None.
FINDINGS: Enlarged level 2 lymph node was identified and removed and sent for pathologic examination.
FLUIDS: Please see anesthesia report.
URINE OUTPUT: None recorded during the case.
INDICATIONS FOR PROCEDURE: This is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy. She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic. After risks and benefits of surgery were discussed with the patient, an informed consent was obtained. She was scheduled for an excisional biopsy of the right cervical lymph node.
PROCEDURE IN DETAIL: The patient was taken to the operating room and placed in the supine position. She was anesthetized with general endotracheal anesthesia. The neck was then prepped and draped in the sterile fashion. Again, noted on palpation there was an enlarged level 2 cervical lymph node.
A 3-cm horizontal incision was made over this lymph node. Dissection was carried down until the sternocleidomastoid muscle was identified. The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation. The area was then explored for any other enlarged lymph nodes. None were identified, and hemostasis was achieved with electrocautery. A quarter-inch Penrose drain was placed in the wound.
The wound was then irrigated and closed with 3-0 interrupted Vicryl sutures for a deep closure followed by a running 4-0 Prolene subcuticular suture. Mastisol and Steri-Strip were placed over the incision, and sterile bandage was applied. The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition. She will return to the office tomorrow in followup to have the Penrose drain removed.
POSTOPERATIVE DIAGNOSIS: Cervical lymphadenopathy.
PROCEDURE: Excisional biopsy of right cervical lymph node.
ANESTHESIA: General endotracheal anesthesia.
SPECIMEN: Right cervical lymph node.
EBL: 10 cc.
COMPLICATIONS: None.
FINDINGS: Enlarged level 2 lymph node was identified and removed and sent for pathologic examination.
FLUIDS: Please see anesthesia report.
URINE OUTPUT: None recorded during the case.
INDICATIONS FOR PROCEDURE: This is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy. She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic. After risks and benefits of surgery were discussed with the patient, an informed consent was obtained. She was scheduled for an excisional biopsy of the right cervical lymph node.
PROCEDURE IN DETAIL: The patient was taken to the operating room and placed in the supine position. She was anesthetized with general endotracheal anesthesia. The neck was then prepped and draped in the sterile fashion. Again, noted on palpation there was an enlarged level 2 cervical lymph node.
A 3-cm horizontal incision was made over this lymph node. Dissection was carried down until the sternocleidomastoid muscle was identified. The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation. The area was then explored for any other enlarged lymph nodes. None were identified, and hemostasis was achieved with electrocautery. A quarter-inch Penrose drain was placed in the wound.
The wound was then irrigated and closed with 3-0 interrupted Vicryl sutures for a deep closure followed by a running 4-0 Prolene subcuticular suture. Mastisol and Steri-Strip were placed over the incision, and sterile bandage was applied. The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition. She will return to the office tomorrow in followup to have the Penrose drain removed.
Sample Name:
Brain Tumor - Consult
Description: The patient was admitted for symptoms that sounded like
postictal state. CT showed edema and slight midline shift. MRI of the brain
shows large inhomogeneous infiltrating right frontotemporal neoplasm
surrounding the right middle cerebral artery.
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REASON FOR CONSULTATION: I was asked by Dr. X to see the patient in regard to his
likely recurrent brain tumor.
HISTORY OF PRESENT ILLNESS: The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was transferred here. He has been seen by Hospitalists Service. He has not had a recurrent seizure. Electroencephalogram shows slowing. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. There is inhomogeneous uptake consistent with potential necrosis. He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm. The patient was diagnosed with a brain tumor in 1999. All details are still not available to us. He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic. That is not available on the chart as I dictate.
After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone. He tolerated that reasonably well. His wife says it's been several years since he had a scan. His behavior had not been changed, until it changed as noted earlier in this summary.
PAST MEDICAL HISTORY: He has had a lumbar fusion. I believe he's had heart disease. Mental status changes are either due to the tumor or other psychiatric problems.
SOCIAL HISTORY: He is living with his wife, next door to one of his children. He has been disabled since 2001, due to the back problems.
REVIEW OF SYSTEMS: No headaches or vision issues. Ongoing heart problems, without complaints. No weakness, numbness or tingling, except that related to his chronic neck pain. No history of endocrine problems. He has nocturia and urinary frequency.
PHYSICAL EXAMINATION: Blood pressure 146/91, pulse 76. Normal conjunctivae. Ears, nose, throat normal. Neck is supple. Chest clear. Heart tones normal. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. No adenopathy in the neck, supraclavicular or axillary regions. Neurologically alert. Cranial nerves are intact. Strength is 5/5 throughout.
LABORATORY WORK: White blood count 10.4, hemoglobin 16, platelets not noted. Sodium 137, calcium 9.1.
IMPRESSION AND PLAN: Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings. Dr. X's note suggests discussing the situation in the tumor board on Wednesday. He is stable enough. The pause in his care would not jeopardize his current status. It would be helpful to get old films and pathology from Abbott Northwestern. However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis. Optimizing his treatment would probably be helped by knowing his current grade of tumor.
HISTORY OF PRESENT ILLNESS: The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was transferred here. He has been seen by Hospitalists Service. He has not had a recurrent seizure. Electroencephalogram shows slowing. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. There is inhomogeneous uptake consistent with potential necrosis. He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm. The patient was diagnosed with a brain tumor in 1999. All details are still not available to us. He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic. That is not available on the chart as I dictate.
After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone. He tolerated that reasonably well. His wife says it's been several years since he had a scan. His behavior had not been changed, until it changed as noted earlier in this summary.
PAST MEDICAL HISTORY: He has had a lumbar fusion. I believe he's had heart disease. Mental status changes are either due to the tumor or other psychiatric problems.
SOCIAL HISTORY: He is living with his wife, next door to one of his children. He has been disabled since 2001, due to the back problems.
REVIEW OF SYSTEMS: No headaches or vision issues. Ongoing heart problems, without complaints. No weakness, numbness or tingling, except that related to his chronic neck pain. No history of endocrine problems. He has nocturia and urinary frequency.
PHYSICAL EXAMINATION: Blood pressure 146/91, pulse 76. Normal conjunctivae. Ears, nose, throat normal. Neck is supple. Chest clear. Heart tones normal. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. No adenopathy in the neck, supraclavicular or axillary regions. Neurologically alert. Cranial nerves are intact. Strength is 5/5 throughout.
LABORATORY WORK: White blood count 10.4, hemoglobin 16, platelets not noted. Sodium 137, calcium 9.1.
IMPRESSION AND PLAN: Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings. Dr. X's note suggests discussing the situation in the tumor board on Wednesday. He is stable enough. The pause in his care would not jeopardize his current status. It would be helpful to get old films and pathology from Abbott Northwestern. However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis. Optimizing his treatment would probably be helped by knowing his current grade of tumor.
Hematology -
Oncology
Sample Name: BRCA-2 mutation
Sample Name: BRCA-2 mutation
Description: Discharge summary of a patient with a BRCA-2 mutation.
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DISCHARGE DIAGNOSES: BRCA-2 mutation.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.
PHYSICAL EXAMINATION: The chest was clear. The abdomen was nontender. Pelvic examination shows no masses. No heart murmur.
HOSPITAL COURSE: The patient underwent surgery on the day of admission. In the postoperative course she was afebrile and unremarkable. The patient regained bowel function and was discharged on the morning of the fourth postoperative day.
OPERATIONS AND PROCEDURES: Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.
PATHOLOGY: A 105-gram uterus without dysplasia or cancer.
CONDITION ON DISCHARGE: Stable.
PLAN: The patient will remain at rest initially with progressive ambulation after. She will avoid lifting, driving or intercourse. She will call me if any fevers, drainage, bleeding, or pain. Follow up in my office in four weeks. Family history, social history, psychosocial needs per the social worker.
DISCHARGE MEDICATIONS: Percocet 5 #40 one every 3 hours p.r.n. pain.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.
PHYSICAL EXAMINATION: The chest was clear. The abdomen was nontender. Pelvic examination shows no masses. No heart murmur.
HOSPITAL COURSE: The patient underwent surgery on the day of admission. In the postoperative course she was afebrile and unremarkable. The patient regained bowel function and was discharged on the morning of the fourth postoperative day.
OPERATIONS AND PROCEDURES: Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.
PATHOLOGY: A 105-gram uterus without dysplasia or cancer.
CONDITION ON DISCHARGE: Stable.
PLAN: The patient will remain at rest initially with progressive ambulation after. She will avoid lifting, driving or intercourse. She will call me if any fevers, drainage, bleeding, or pain. Follow up in my office in four weeks. Family history, social history, psychosocial needs per the social worker.
DISCHARGE MEDICATIONS: Percocet 5 #40 one every 3 hours p.r.n. pain.
Sample Name:
Breast Cancer Followup
Description: A nurse with a history of breast cancer enrolled is clinical
trial C40502. Her previous treatments included Zometa, Faslodex, and Aromasin.
She was found to have disease progression first noted by rising tumor markers.
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CHIEF COMPLAINT:
1. Metastatic breast cancer.
2. Enrolled is clinical trial C40502.
3. Sinus pain.
HISTORY OF PRESENT ILLNESS: She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502. She was randomized to the ixabepilone plus Avastin. She experienced dose-limiting toxicity with the fourth cycle. The Ixempra was skipped on day 1 and day 8. She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy. Early in the month she had concerned about possible perforated septum. She was seen by ENT urgently. She was found to have nasal septum intact. She comes into clinic today for day eight Ixempra.
CURRENT MEDICATIONS: Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.
ALLERGIES: Compazine.
REVIEW OF SYSTEMS: The patient is comfort in knowing that she does not have a septal perforation. She has progressive neuropathy and decreased sensation in her fingertips. She makes many errors when keyboarding. I would rate her neuropathy as grade 2. She continues to have headaches respond to Ultram which she takes as needed. She occasionally reports pain in her right upper quadrant as well as right sternum. He denies any fevers, chills, or night sweats. Her diarrhea has finally resolved and her bowels are back to normal. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 113/63. HEART RATE: 84. TEMP: 99. Weight: 67.8 kg. Her performance status is 1.
GEN: She looks well, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Her oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. She has positive bowel sounds. No hepatosplenomegaly.
EXT: Lower extremities are without edema.
LABORATORY DATA: White blood cell count is 7.6, hemoglobin 12.6, hematocrit 37.5, and platelets 287,000.
ASSESSMENT/PLAN: This is a very pleasant 59-year-old female with metastatic breast cancer. She is enrolled in clinical trial C40502. She has completed nine cycles of chemotherapy with Ixempra plus Avastin. First we thought she might suffered a perforated septum which would bring up concerns with the Avastin. There have been isolated cases reported of nasal septum perforation that is thought to be related to the Avastin. She was noted to have a thin septum but it is intact. We will continue her treatment as planned. I will see her clinic in four weeks.
1. Metastatic breast cancer.
2. Enrolled is clinical trial C40502.
3. Sinus pain.
HISTORY OF PRESENT ILLNESS: She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502. She was randomized to the ixabepilone plus Avastin. She experienced dose-limiting toxicity with the fourth cycle. The Ixempra was skipped on day 1 and day 8. She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy. Early in the month she had concerned about possible perforated septum. She was seen by ENT urgently. She was found to have nasal septum intact. She comes into clinic today for day eight Ixempra.
CURRENT MEDICATIONS: Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.
ALLERGIES: Compazine.
REVIEW OF SYSTEMS: The patient is comfort in knowing that she does not have a septal perforation. She has progressive neuropathy and decreased sensation in her fingertips. She makes many errors when keyboarding. I would rate her neuropathy as grade 2. She continues to have headaches respond to Ultram which she takes as needed. She occasionally reports pain in her right upper quadrant as well as right sternum. He denies any fevers, chills, or night sweats. Her diarrhea has finally resolved and her bowels are back to normal. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 113/63. HEART RATE: 84. TEMP: 99. Weight: 67.8 kg. Her performance status is 1.
GEN: She looks well, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Her oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. She has positive bowel sounds. No hepatosplenomegaly.
EXT: Lower extremities are without edema.
LABORATORY DATA: White blood cell count is 7.6, hemoglobin 12.6, hematocrit 37.5, and platelets 287,000.
ASSESSMENT/PLAN: This is a very pleasant 59-year-old female with metastatic breast cancer. She is enrolled in clinical trial C40502. She has completed nine cycles of chemotherapy with Ixempra plus Avastin. First we thought she might suffered a perforated septum which would bring up concerns with the Avastin. There have been isolated cases reported of nasal septum perforation that is thought to be related to the Avastin. She was noted to have a thin septum but it is intact. We will continue her treatment as planned. I will see her clinic in four weeks.
Sample Name:
Breast Cancer Followup - 1
Description: Stage IIA right breast cancer. The pathology showed an
infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive,
PR positive and HER-2/neu negative.
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CHIEF COMPLAINT: Stage IIA right breast cancer.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right breast. On 02/10/08, she underwent an ultrasound-guided biopsy. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy. The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative. Therefore it was a T2, N0, M0 stage IIA breast cancer. Of note, at that time she was taking hormone replacement therapy and that was stopped. She underwent radiation treatment ending in May 2008. She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara. She also did not tolerate the Femara and I changed it to tamoxifen. She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy. She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen. When I saw her on 04/28/10, she was really doing quite well with tamoxifen. She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself. She is not going take to any further tamoxifen.
Overall, she is feeling well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.
ALLERGIES: Sulfa, Betadine, and IV contrast.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. Asthma.
2. Hypertension.
3. GERD.
4. Eczema.
5. Status post three cesarean sections.
6. Status post a hysterectomy in 1981 for fibroids. They also removed one ovary.
7. Status post a cholecystectomy in 1993.
8. She has a history of a positive TB test.
9. She is status post repair of ventral hernia in November 2008.
SOCIAL HISTORY: She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher.
FAMILY HISTORY: Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.
PHYSICAL EXAM:
VIT: Height 163 cm, weight 66.8 kg, blood pressure 114/80, pulse 72, and temperature is 97.6.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Stage IIA right breast cancer. Overall she is doing well. Her CBC and CMP were acceptable. I am going to see her again in November.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right breast. On 02/10/08, she underwent an ultrasound-guided biopsy. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy. The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative. Therefore it was a T2, N0, M0 stage IIA breast cancer. Of note, at that time she was taking hormone replacement therapy and that was stopped. She underwent radiation treatment ending in May 2008. She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara. She also did not tolerate the Femara and I changed it to tamoxifen. She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy. She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen. When I saw her on 04/28/10, she was really doing quite well with tamoxifen. She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself. She is not going take to any further tamoxifen.
Overall, she is feeling well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.
ALLERGIES: Sulfa, Betadine, and IV contrast.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. Asthma.
2. Hypertension.
3. GERD.
4. Eczema.
5. Status post three cesarean sections.
6. Status post a hysterectomy in 1981 for fibroids. They also removed one ovary.
7. Status post a cholecystectomy in 1993.
8. She has a history of a positive TB test.
9. She is status post repair of ventral hernia in November 2008.
SOCIAL HISTORY: She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher.
FAMILY HISTORY: Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.
PHYSICAL EXAM:
VIT: Height 163 cm, weight 66.8 kg, blood pressure 114/80, pulse 72, and temperature is 97.6.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Stage IIA right breast cancer. Overall she is doing well. Her CBC and CMP were acceptable. I am going to see her again in November.
Sample Name:
Breast Mass Excision
Description: Excision of right breast mass. Right breast mass with
atypical proliferative cells on fine-needle aspiration.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right breast mass with atypical proliferative cells on
fine-needle aspiration.
POSTOPERATIVE DIAGNOSIS: Benign breast mass.
ANESTHESIA: General
NAME OF OPERATION: Excision of right breast mass.
PROCEDURE: With the patient in the supine position, the right breast was prepped and draped in a sterile fashion. A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast. Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue. Hemostasis was obtained using electrocautery. Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign. The breast tissues were approximated using 4-0 Vicryl. The skin was closed using 5-0 Vicryl running subcuticular stitches. A sterile bandage was applied. The patient tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Benign breast mass.
ANESTHESIA: General
NAME OF OPERATION: Excision of right breast mass.
PROCEDURE: With the patient in the supine position, the right breast was prepped and draped in a sterile fashion. A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast. Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue. Hemostasis was obtained using electrocautery. Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign. The breast tissues were approximated using 4-0 Vicryl. The skin was closed using 5-0 Vicryl running subcuticular stitches. A sterile bandage was applied. The patient tolerated the procedure well.
Sample Name:
Breast Mass Excision - 1
Description: Left breast mass and hypertrophic scar of the left breast.
Excision of left breast mass and revision of scar. The patient is status post
left breast biopsy, which showed a fibrocystic disease with now a palpable mass
just superior to the previous biopsy site.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Hypertrophic scar of the left breast.
POSTOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Hypertrophic scar of the left breast.
PROCEDURE PERFORMED: Excision of left breast mass and revision of scar.
ANESTHESIA: Local with sedation.
SPECIMEN: Scar with left breast mass.
DISPOSITION: The patient tolerated the procedure well and transferred to the recover room in stable condition.
BRIEF HISTORY: The patient is an 18-year-old female who presented to Dr. X's office. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. The patient also has a hypertrophic scar. Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.
INTRAOPERATIVE FINDINGS: A hypertrophic scar was found and removed. The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.
PROCEDURE: After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion. Elliptical incision was made over the previous cicatrix. The total length of the incision was 5.5 cm. Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine. Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery. Hemostasis was maintained. Attention was next made to approximating the deep dermal layers. An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges. Steri-Strips as well as bacitracin and sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition.
1. Left breast mass.
2. Hypertrophic scar of the left breast.
POSTOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Hypertrophic scar of the left breast.
PROCEDURE PERFORMED: Excision of left breast mass and revision of scar.
ANESTHESIA: Local with sedation.
SPECIMEN: Scar with left breast mass.
DISPOSITION: The patient tolerated the procedure well and transferred to the recover room in stable condition.
BRIEF HISTORY: The patient is an 18-year-old female who presented to Dr. X's office. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. The patient also has a hypertrophic scar. Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.
INTRAOPERATIVE FINDINGS: A hypertrophic scar was found and removed. The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.
PROCEDURE: After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion. Elliptical incision was made over the previous cicatrix. The total length of the incision was 5.5 cm. Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine. Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery. Hemostasis was maintained. Attention was next made to approximating the deep dermal layers. An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges. Steri-Strips as well as bacitracin and sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition.
Sample Name:
Breast Mass Excision - 2
Description: Excision of left breast mass. The mass was identified
adjacent to the left nipple. It was freely mobile and it did not seem to hold
the skin.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Breast mass, left.
POSTOPERATIVE DIAGNOSIS: Breast mass, left.
PROCEDURE: Excision of left breast mass.
OPERATION: After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Preoperative antibiotic was given. The patient was prepped and draped in the usual fashion. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc. Hemostasis was achieved with the cautery. The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl. A small pressure dressing was applied.
Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Breast mass, left.
PROCEDURE: Excision of left breast mass.
OPERATION: After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Preoperative antibiotic was given. The patient was prepped and draped in the usual fashion. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc. Hemostasis was achieved with the cautery. The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl. A small pressure dressing was applied.
Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.
Hematology -
Oncology
Sample Name: Breast Radiation Therapy Followup
Sample Name: Breast Radiation Therapy Followup
Description: Breast radiation therapy followup note. Left breast
adenocarcinoma stage T3 N1b M0, stage IIIA.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
DIAGNOSIS: Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.
She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.
CURRENT MEDICATIONS
1. Glucosamine complex.
2. Toprol XL.
3. Alprazolam
4. Hydrochlorothiazide.
5. Dyazide.
6. Centrum.
Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.
PHYSICAL EXAMINATION
NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.
RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.
ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.
I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.
She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.
CURRENT MEDICATIONS
1. Glucosamine complex.
2. Toprol XL.
3. Alprazolam
4. Hydrochlorothiazide.
5. Dyazide.
6. Centrum.
Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.
PHYSICAL EXAMINATION
NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.
RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.
ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.
I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.
Sample Name:
Cancer of the nasopharynx
Description: T1 N3 M0 cancer of the nasopharynx, status post radiation
therapy with 2 cycles of high dose cisplatin with radiation.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
DIAGNOSIS: T1 N3 M0 cancer of the nasopharynx, status post radiation
therapy with 2 cycles of high dose cisplatin with radiation, completed June,
2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy,
completed September, 2006; hearing loss related to chemotherapy and radiation;
xerostomia; history of left upper extremity deep venous thrombosis.
PERFORMANCE STATUS: 0.
INTERVAL HISTORY: In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.
PHYSICAL EXAMINATION:
Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.
HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.
Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.
Lungs: Clear.
Cardiac: Rhythm regular.
Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.
Lower Extremities: Without edema.
Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.
I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.
Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.
He is on no current medications.
In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.
He returns to the general care and direction of Dr. ABC.
PERFORMANCE STATUS: 0.
INTERVAL HISTORY: In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.
PHYSICAL EXAMINATION:
Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.
HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.
Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.
Lungs: Clear.
Cardiac: Rhythm regular.
Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.
Lower Extremities: Without edema.
Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.
I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.
Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.
He is on no current medications.
In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.
He returns to the general care and direction of Dr. ABC.
Sample Name:
Cholangiocarcinoma Consult
Description: Newly diagnosed cholangiocarcinoma. The patient is noted to
have an increase in her liver function tests on routine blood work. Ultrasound
of the abdomen showed gallbladder sludge and gallbladder findings consistent
with adenomyomatosis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Newly diagnosed cholangiocarcinoma.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.
PAST MEDICAL HISTORY: Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.
CURRENT MEDICATIONS: Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.
SOCIAL HISTORY: The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.
REVIEW OF SYSTEMS: The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 108/60. HEART RATE: 80. TEMP: 98.5. Weight: 75 kg.
GEN: She is a very pleasant female, in no acute distress.
HEENT: She has obvious strabismus of the left eye with medial deviation. Her pupils are equal, round, and reactive to light. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft, nontender, and nondistended. No palpable masses. No hepatosplenomegaly.
EXT: Lower extremities are without edema.
LABORATORY STUDIES: Sodium 141, glucose 111, total bilirubin 2.3, alkaline phosphatase 941, AST 161, and ALT 220. White blood cell count 4.3, hemoglobin 11.6, hematocrit 35, and platelets 156,000. Total bilirubin from August 25, 2010 was 1.6, alkaline phosphatase 735, AST 123, ALT 184, CA99 is 109. Bile duct brushings are notable for atypical cell clusters present, highly suspicious for carcinoma.
ASSESSMENT/PLAN: This is a very pleasant 77-year-old female who has findings suspicious for a cholangiocarcinoma. The patient was referred to our office to discuss this diagnosis. I spent greater than an hour with the patient and her husband discussing this potential diagnosis, reviewing the anatomy and answering questions. She is yet to have a surgical consultation, and we discussed the difficulty that we sometimes have with patients meeting surgical criteria to manage cholangiocarcinoma. The patient also had questions about the Medical University and possibly seeking a second opinion. She will contact our office after her surgical consultation if she needs assistance with obtaining a second opinion. We also talked about our clinical research program here. Currently, we do have a Phase II Study for advanced gallbladder carcinoma or cholangiocarcinoma for patients that are unresectable. We will go ahead and provide her with a consent form so that she can look that over and it will give her some more information about the malignancy and treatment approaches. We will schedule her for followup in three weeks. We will also schedule her for PET/CT scan for staging.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.
PAST MEDICAL HISTORY: Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.
CURRENT MEDICATIONS: Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.
SOCIAL HISTORY: The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.
REVIEW OF SYSTEMS: The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 108/60. HEART RATE: 80. TEMP: 98.5. Weight: 75 kg.
GEN: She is a very pleasant female, in no acute distress.
HEENT: She has obvious strabismus of the left eye with medial deviation. Her pupils are equal, round, and reactive to light. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft, nontender, and nondistended. No palpable masses. No hepatosplenomegaly.
EXT: Lower extremities are without edema.
LABORATORY STUDIES: Sodium 141, glucose 111, total bilirubin 2.3, alkaline phosphatase 941, AST 161, and ALT 220. White blood cell count 4.3, hemoglobin 11.6, hematocrit 35, and platelets 156,000. Total bilirubin from August 25, 2010 was 1.6, alkaline phosphatase 735, AST 123, ALT 184, CA99 is 109. Bile duct brushings are notable for atypical cell clusters present, highly suspicious for carcinoma.
ASSESSMENT/PLAN: This is a very pleasant 77-year-old female who has findings suspicious for a cholangiocarcinoma. The patient was referred to our office to discuss this diagnosis. I spent greater than an hour with the patient and her husband discussing this potential diagnosis, reviewing the anatomy and answering questions. She is yet to have a surgical consultation, and we discussed the difficulty that we sometimes have with patients meeting surgical criteria to manage cholangiocarcinoma. The patient also had questions about the Medical University and possibly seeking a second opinion. She will contact our office after her surgical consultation if she needs assistance with obtaining a second opinion. We also talked about our clinical research program here. Currently, we do have a Phase II Study for advanced gallbladder carcinoma or cholangiocarcinoma for patients that are unresectable. We will go ahead and provide her with a consent form so that she can look that over and it will give her some more information about the malignancy and treatment approaches. We will schedule her for followup in three weeks. We will also schedule her for PET/CT scan for staging.
Hematology -
Oncology
Sample Name: Colon Polyps - Genetic Counseling
Sample Name: Colon Polyps - Genetic Counseling
Description: Genetic counseling for a strong family history of colon
polyps. She has had colonoscopies required every five years and every time she
has polyps were found. She reports that of her 11 brothers and sister 7 have
had precancerous polyps.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULT: Genetic counseling.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.
PAST MEDICAL HISTORY: Significant for asthma.
CURRENT MEDICATIONS: Include Serevent two puffs daily and Nasonex two sprays daily.
ALLERGIES: Include penicillin. She is also allergic seafood; crab and mobster.
SOCIAL HISTORY: The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.
REVIEW OF SYSTEMS: The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 110/58. HEART RATE: 76. TEMP: 98.2. Weight: 79.1 kg.
GEN: She is very pleasant female, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. She has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
ASSESSMENT/PLAN: This is a 61-year-old female with strong family history of colon polyps. The patient reports that her siblings have been very diligent about their preventing health and no one besides her sister who presented with the advanced breast cancer add anything more than precancerous adenomas. We will plan on proceeding with testing for adenomatous polyps. I will see her back in clinic once we get the results. I appreciate the referral.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.
PAST MEDICAL HISTORY: Significant for asthma.
CURRENT MEDICATIONS: Include Serevent two puffs daily and Nasonex two sprays daily.
ALLERGIES: Include penicillin. She is also allergic seafood; crab and mobster.
SOCIAL HISTORY: The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.
REVIEW OF SYSTEMS: The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 110/58. HEART RATE: 76. TEMP: 98.2. Weight: 79.1 kg.
GEN: She is very pleasant female, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. She has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
ASSESSMENT/PLAN: This is a 61-year-old female with strong family history of colon polyps. The patient reports that her siblings have been very diligent about their preventing health and no one besides her sister who presented with the advanced breast cancer add anything more than precancerous adenomas. We will plan on proceeding with testing for adenomatous polyps. I will see her back in clinic once we get the results. I appreciate the referral.
Sample Name:
Concomitant Chemoradiotherapy
Description: Concomitant chemoradiotherapy for curative intent patients.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CONCOMITANT CHEMORADIOTHERAPY FOR
CURATIVE INTENT PATIENTS
This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells. It has been shown in the literature that this will maximize the chance of control.
During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course. It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held. This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects. In accordance, this requires more frequency consultation and coordination with the medical oncologist. Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.
This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells. It has been shown in the literature that this will maximize the chance of control.
During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course. It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held. This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects. In accordance, this requires more frequency consultation and coordination with the medical oncologist. Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.
Sample Name:
Conformal Simulation
Description: Conformal simulation with coplanar beams. This patient is
undergoing a conformal simulation as the method to precisely define the area of
disease which needs to be treated.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CONFORMAL SIMULATION WITH COPLANAR
BEAMS
This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues. This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.
A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort. The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized. One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields). Radiographs are taken, and these fields are marked on the patient's skin. The patient is then transferred to the diagnostic facility and placed on a flat CT scan table. Scans are then performed through the targeted area. The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan. The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures. This volume is then reconstructed in 3-dimensional space. Utilizing the beam's-eye view features, the appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures. Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, Cerrobend blocks will be custom fabricated.
If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.
This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues. This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.
A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort. The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized. One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields). Radiographs are taken, and these fields are marked on the patient's skin. The patient is then transferred to the diagnostic facility and placed on a flat CT scan table. Scans are then performed through the targeted area. The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan. The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures. This volume is then reconstructed in 3-dimensional space. Utilizing the beam's-eye view features, the appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures. Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, Cerrobend blocks will be custom fabricated.
If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.
Hematology -
Oncology
Sample Name: Consult - Breast Cancer
Sample Name: Consult - Breast Cancer
Description: Patient presents with complaint of lump in the upper outer
quadrant of the right breast
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT / REASON FOR THE
VISIT: Patient has been diagnosed to have
breast cancer.
BREAST CANCER HISTORY: Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.
PATHOLOGY: Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.
STAGE: Stage I.
TNM STAGE: T1, N0 and M0.
SURGERY: S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.
PAST MEDICAL HISTORY: Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.
SCREENING TEST HISTORY: Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.
IMMUNIZATION HISTORY: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.
FAMILY MEDICAL HISTORY: Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.
PAST SURGICAL HISTORY: Appendectomy. Biopsy of the left breast 1996 - benign. Cholecystectomy.
PERSONAL AND SOCIAL HISTORY: Marital status: Married. Smoking history: Smoked 1 PPD, quit 12 years ago and after smoking for 30 years. Alcohol history: Drinks socially. Denies any history of drug abuse.
ALLERGIES: There are no known drug allergies.
CURRENT MEDICATIONS: Aspirin 1 tab x 1 / day. Calan SR 120 mg. x 1 / day.
REVIEW OF SYSTEMS:
General: Patient feels fairly well. Patient denies history of fever, chills, night sweats and weight loss.
Head and Eyes: Patient denies any problems relating to the head and eyes.
Ears Nose and Throat: Patient has no problems related to the ears, nose or throat.
Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.
Cardiovascular: Chest pain in the retrosternal area, Occasional anginal pain and patient describes it as a sensation of tightness. It radiates to the left shoulder. Patient denies any palpitation, syncope, paroxysmal nocturnal dyspnea and orthopnea.
Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.
Genitourinary: Denies any genito-urinary complaints.
Musculoskeletal: The patient denies any musculoskeletal complaints.
Neurological: Patient denies any focal motor, sensory or other neurological symptoms.
PHYSICAL EXAMINATION:
General: Patient appears well developed, well nourished and healthy. Personality: pleasant and cooperative. Mental status: Alert and oriented. Stature: slender. ECOG performance score 0.
HEENT: Examination of head, eyes, ears, nose and throat is unremarkable.
Hematologic / Lymphatic: There is no palpable adenopathy in the inguinal, axillary, or cervical areas.
Cardiovascular: Heart: Regular rhythm, normal rate without any murmurs or gallops.
Breast: RIGHT BREAST: Within normal limits. LEFT BREAST: Consistency: slight induration noted due to recent surgery.
Respiratory: Chest symmetrical, normal, breath sounds equal, bilateral symmetrical, no rales or rhonchi and no
dullness to percussion.
Abdomen / Gastrointestinal: Abdomen is soft, non-tender, and without palpable masses. No hepatosplenomegaly is appreciable.
Extremities: Peripheral pulses are normal. There is no edema, cyanosis, clubbing or significant varicosities. No skin lesions identified.
Musculoskelatal: No evidence of joint swelling, bone tenderness or muscle tenderness is appreciable.
Neurological: Brief neurological examination reveals motor power grossly normal in all groups and no gross sensory or other abnormality appreciable.
RADIOLOGY: Mammogram: A mass measuring 2X2 cm. in the upper outer quadrant of the left breast. Lab:
LAB DATA: CMP (comprehensive metabolic panel): WNL. Liver function tests are WNL. CBC with diff shows WBC 3.2 / cmm. Hemoglobin 12.0 grams / dl, Platelets 250000 / cmm and it is dated 1/4/2000.
IMPRESSION / DIAGNOSIS : Carcinoma of the left breast (174.9 - female), Upper outer quadrant (174.4)
PATHOLOGY: Infiltrating ductal carcinoma. S/P lumpectomy and axillary node dissection. (Details as per HPI).
DISCUSSION: Discussed in detail the diagnosis, prognosis and treatment alternatives. Options of treatment discussed. Side effects of Tamoxifen discussed in detail.
RECOMMENDATIONS: Hormonal therapy with Tamoxifen and Radiation therapy to the breast is recommended.
TESTS ORDERED: The following labs are to be drawn about a week or so prior to next appointment:
HEMATOLOGY: CBC.
CHEMISTRY: comprehensive metabolic panel (CMP) and liver function panel (LFT).
MEDICATIONS PRESCRIBED: Nolvadex 20 mg. 1 time a day.
FOLLOW-UP INSTRUCTIONS: Return to see William Smith.M.D. for follow up in 3 month (s). Make appointment to Radiation therapy.
BREAST CANCER HISTORY: Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.
PATHOLOGY: Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.
STAGE: Stage I.
TNM STAGE: T1, N0 and M0.
SURGERY: S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.
PAST MEDICAL HISTORY: Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.
SCREENING TEST HISTORY: Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.
IMMUNIZATION HISTORY: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.
FAMILY MEDICAL HISTORY: Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.
PAST SURGICAL HISTORY: Appendectomy. Biopsy of the left breast 1996 - benign. Cholecystectomy.
PERSONAL AND SOCIAL HISTORY: Marital status: Married. Smoking history: Smoked 1 PPD, quit 12 years ago and after smoking for 30 years. Alcohol history: Drinks socially. Denies any history of drug abuse.
ALLERGIES: There are no known drug allergies.
CURRENT MEDICATIONS: Aspirin 1 tab x 1 / day. Calan SR 120 mg. x 1 / day.
REVIEW OF SYSTEMS:
General: Patient feels fairly well. Patient denies history of fever, chills, night sweats and weight loss.
Head and Eyes: Patient denies any problems relating to the head and eyes.
Ears Nose and Throat: Patient has no problems related to the ears, nose or throat.
Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.
Cardiovascular: Chest pain in the retrosternal area, Occasional anginal pain and patient describes it as a sensation of tightness. It radiates to the left shoulder. Patient denies any palpitation, syncope, paroxysmal nocturnal dyspnea and orthopnea.
Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.
Genitourinary: Denies any genito-urinary complaints.
Musculoskeletal: The patient denies any musculoskeletal complaints.
Neurological: Patient denies any focal motor, sensory or other neurological symptoms.
PHYSICAL EXAMINATION:
General: Patient appears well developed, well nourished and healthy. Personality: pleasant and cooperative. Mental status: Alert and oriented. Stature: slender. ECOG performance score 0.
HEENT: Examination of head, eyes, ears, nose and throat is unremarkable.
Hematologic / Lymphatic: There is no palpable adenopathy in the inguinal, axillary, or cervical areas.
Cardiovascular: Heart: Regular rhythm, normal rate without any murmurs or gallops.
Breast: RIGHT BREAST: Within normal limits. LEFT BREAST: Consistency: slight induration noted due to recent surgery.
Respiratory: Chest symmetrical, normal, breath sounds equal, bilateral symmetrical, no rales or rhonchi and no
dullness to percussion.
Abdomen / Gastrointestinal: Abdomen is soft, non-tender, and without palpable masses. No hepatosplenomegaly is appreciable.
Extremities: Peripheral pulses are normal. There is no edema, cyanosis, clubbing or significant varicosities. No skin lesions identified.
Musculoskelatal: No evidence of joint swelling, bone tenderness or muscle tenderness is appreciable.
Neurological: Brief neurological examination reveals motor power grossly normal in all groups and no gross sensory or other abnormality appreciable.
RADIOLOGY: Mammogram: A mass measuring 2X2 cm. in the upper outer quadrant of the left breast. Lab:
LAB DATA: CMP (comprehensive metabolic panel): WNL. Liver function tests are WNL. CBC with diff shows WBC 3.2 / cmm. Hemoglobin 12.0 grams / dl, Platelets 250000 / cmm and it is dated 1/4/2000.
IMPRESSION / DIAGNOSIS : Carcinoma of the left breast (174.9 - female), Upper outer quadrant (174.4)
PATHOLOGY: Infiltrating ductal carcinoma. S/P lumpectomy and axillary node dissection. (Details as per HPI).
DISCUSSION: Discussed in detail the diagnosis, prognosis and treatment alternatives. Options of treatment discussed. Side effects of Tamoxifen discussed in detail.
RECOMMENDATIONS: Hormonal therapy with Tamoxifen and Radiation therapy to the breast is recommended.
TESTS ORDERED: The following labs are to be drawn about a week or so prior to next appointment:
HEMATOLOGY: CBC.
CHEMISTRY: comprehensive metabolic panel (CMP) and liver function panel (LFT).
MEDICATIONS PRESCRIBED: Nolvadex 20 mg. 1 time a day.
FOLLOW-UP INSTRUCTIONS: Return to see William Smith.M.D. for follow up in 3 month (s). Make appointment to Radiation therapy.
Sample Name:
Consult - Breast Cancer - 1
Description: The patient is a 57-year-old female with invasive ductal
carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Left breast cancer.
HISTORY: The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial). The biopsy returned showing infiltrating ductal carcinoma high histologic grade. The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging. She prior to that area, denied any complaints. She had no nipple discharge. No trauma history. She has had been on no estrogen supplementation. She has had no other personal history of breast cancer. Her family history is positive for her mother having breast cancer at age 48. The patient has had no children and no pregnancies. She denies any change in the right breast. Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y. I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy. The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning. The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact. CT scan of the neck, chest, and abdomen is negative for metastatic disease.
PAST MEDICAL HISTORY: Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.
MEDICATIONS: She is currently on omeprazole for reflux and indigestion.
ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: Negative for any recent febrile illnesses, chest pains or shortness of breath. Positive for restless leg syndrome. Negative for any unexplained weight loss and no change in bowel or bladder habits.
FAMILY HISTORY: Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.
SOCIAL HISTORY: The patient works as a school teacher and teaching high school.
PHYSICAL EXAMINATION
GENERAL: The patient is a white female, alert and oriented x 3, appears her stated age of 57.
HEENT: Head is atraumatic and normocephalic. Sclerae are anicteric.
NECK: Supple.
CHEST: Clear.
HEART: Regular rate and rhythm.
BREASTS: Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle. There are no nipple retractions. No skin dimpling. There is some, at the time of the office visit, ecchymosis from recent biopsy. There is no axillary adenopathy. The remainder of the left breast is without abnormality. The right breast is without abnormality. The axillary areas are negative for adenopathy bilaterally.
ABDOMEN: Soft, nontender without masses. No gross organomegaly. No CVA or flank tenderness.
EXTREMITIES: Grossly neurovascularly intact.
IMPRESSION: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.
RECOMMENDATIONS: I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy. We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection. The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient. The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained. Local numbness, paresthesias or chronic pain was explained. The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers. She was certainly encouraged to obtain further surgical medical opinions prior to proceeding. I believe the patient has given full informed consent and desires to proceed with the above.
HISTORY: The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial). The biopsy returned showing infiltrating ductal carcinoma high histologic grade. The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging. She prior to that area, denied any complaints. She had no nipple discharge. No trauma history. She has had been on no estrogen supplementation. She has had no other personal history of breast cancer. Her family history is positive for her mother having breast cancer at age 48. The patient has had no children and no pregnancies. She denies any change in the right breast. Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y. I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy. The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning. The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact. CT scan of the neck, chest, and abdomen is negative for metastatic disease.
PAST MEDICAL HISTORY: Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.
MEDICATIONS: She is currently on omeprazole for reflux and indigestion.
ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: Negative for any recent febrile illnesses, chest pains or shortness of breath. Positive for restless leg syndrome. Negative for any unexplained weight loss and no change in bowel or bladder habits.
FAMILY HISTORY: Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.
SOCIAL HISTORY: The patient works as a school teacher and teaching high school.
PHYSICAL EXAMINATION
GENERAL: The patient is a white female, alert and oriented x 3, appears her stated age of 57.
HEENT: Head is atraumatic and normocephalic. Sclerae are anicteric.
NECK: Supple.
CHEST: Clear.
HEART: Regular rate and rhythm.
BREASTS: Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle. There are no nipple retractions. No skin dimpling. There is some, at the time of the office visit, ecchymosis from recent biopsy. There is no axillary adenopathy. The remainder of the left breast is without abnormality. The right breast is without abnormality. The axillary areas are negative for adenopathy bilaterally.
ABDOMEN: Soft, nontender without masses. No gross organomegaly. No CVA or flank tenderness.
EXTREMITIES: Grossly neurovascularly intact.
IMPRESSION: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.
RECOMMENDATIONS: I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy. We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection. The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient. The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained. Local numbness, paresthesias or chronic pain was explained. The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers. She was certainly encouraged to obtain further surgical medical opinions prior to proceeding. I believe the patient has given full informed consent and desires to proceed with the above.
Hematology -
Oncology
Sample Name: Craniopharyngioma - Postop
Sample Name: Craniopharyngioma - Postop
Description: Postoperative visit for craniopharyngioma with residual
disease. According to him, he is doing well, back at school without any
difficulties. He has some occasional headaches and tinnitus, but his vision is
much improved.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR VISIT: Postoperative visit for craniopharyngioma.
HISTORY OF PRESENT ILLNESS: Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.
MEDICATIONS: Synthroid 100 mcg per day.
FINDINGS: On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed.
The postoperative MRI demonstrates small residual disease.
Histology returned as craniopharyngioma.
ASSESSMENT: Postoperative visit for craniopharyngioma with residual disease.
PLANS: I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.
HISTORY OF PRESENT ILLNESS: Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.
MEDICATIONS: Synthroid 100 mcg per day.
FINDINGS: On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed.
The postoperative MRI demonstrates small residual disease.
Histology returned as craniopharyngioma.
ASSESSMENT: Postoperative visit for craniopharyngioma with residual disease.
PLANS: I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.
Sample Name:
Discharge Summary - Mesothelioma
Description: A patient with preoperative diagnosis of right pleural mass
and postoperative diagnosis of mesothelioma.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right pleural mass.
POSTOPERATIVE DIAGNOSIS: Mesothelioma.
PROCEDURES PERFORMED:
1. Flexible bronchoscopy.
2. Mediastinoscopy.
3. Right thoracotomy.
4. Parietal pleural biopsy.
CONSULTS:
Consults obtained during this hospitalization included:
1. Radiation Oncology.
2. Pulmonary Medicine.
3. Medical Oncology.
4. Cancer Center Team consult.
5. Massage therapy consult.
HOSPITAL COURSE: The patient's hospital course was unremarkable. Her pain was well controlled with an epidural that was placed by Anesthesia. At the time of discharge, the patient was ambulatory. She was discharged with home oxygen available. She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d. She was discharged with a prescription for Vicodin for pain control. She is to follow up with Dr. X in the office in one week with a chest x-ray. She is instructed not to lift, push or pull anything greater than 10 pounds. She is instructed not to drive until after she sees us in the office and is off her pain medications.
POSTOPERATIVE DIAGNOSIS: Mesothelioma.
PROCEDURES PERFORMED:
1. Flexible bronchoscopy.
2. Mediastinoscopy.
3. Right thoracotomy.
4. Parietal pleural biopsy.
CONSULTS:
Consults obtained during this hospitalization included:
1. Radiation Oncology.
2. Pulmonary Medicine.
3. Medical Oncology.
4. Cancer Center Team consult.
5. Massage therapy consult.
HOSPITAL COURSE: The patient's hospital course was unremarkable. Her pain was well controlled with an epidural that was placed by Anesthesia. At the time of discharge, the patient was ambulatory. She was discharged with home oxygen available. She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d. She was discharged with a prescription for Vicodin for pain control. She is to follow up with Dr. X in the office in one week with a chest x-ray. She is instructed not to lift, push or pull anything greater than 10 pounds. She is instructed not to drive until after she sees us in the office and is off her pain medications.
Sample Name:
Discharge Summary - Mesothelioma - 1
Description: Mesothelioma, pleural effusion, atrial fibrillation, anemia,
ascites, esophageal reflux, and history of deep venous thrombosis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PRINCIPAL DIAGNOSIS: Mesothelioma.
SECONDARY DIAGNOSES: Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.
PROCEDURES
1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.
2. On August 20, 2007, thoracentesis.
3. On August 31, 2007, Port-A-Cath placement.
HISTORY AND PHYSICAL: The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion.
PAST MEDICAL HISTORY
1. Pericardectomy.
2. Pericarditis.
2. Atrial fibrillation.
4. RNCA with intracranial thrombolytic treatment.
5 PTA of MCA.
6. Mesenteric venous thrombosis.
7. Pericardial window.
8. Cholecystectomy.
9. Left thoracentesis.
FAMILY HISTORY: No family history of coronary artery disease, CVA, diabetes, CHF or MI. The patient has one family member, a sister, with history of cancer.
SOCIAL HISTORY: She is married. Employed with the US Post Office. She is a mother of three. Denies tobacco, alcohol or illicit drug use.
MEDICATIONS
1. Coumadin 1 mg daily. Last INR was on Tuesday, August 14, 2007, and her INR was 2.3.
2. Amiodarone 100 mg p.o. daily.
REVIEW OF SYSTEMS: Complete review of systems negative except as in pulmonary as noted above. The patient also reports occasional numbness and tingling of her left arm.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 123/95, heart rate 83, respirations 20, temperature 97, and oxygen saturation 97%.
GENERAL: Positive nonproductive cough and pain with coughing.
HEENT: Pupils are equal and reactive to light and accommodation. Tympanic membranes are clear.
NECK: Supple. No lymphadenopathy. No masses.
RESPIRATORY: Pleural friction rub is noted.
GI: Soft, nondistended, and nontender. Positive bowel sounds. No organomegaly.
EXTREMITIES: No edema, no clubbing, no cyanosis, no tenderness. Full range of motion. Normal pulses in all extremities.
SKIN: No breakdown or lesions. No ulcers.
NEUROLOGIC: Grossly intact. No focal deficits. Awake, alert, and oriented to person, place, and time.
LABORATORY DATA: Labs are pending.
HOSPITAL COURSE: The patient was admitted for a right-sided pleural effusion for thoracentesis on Monday by Dr. X. Her Coumadin was placed on hold. A repeat echocardiogram was checked. She was started on prophylaxis for DVT with Lovenox 40 mg subcutaneously. Her history dated back to March 2005 when she first sought medical attention for evidence of pericarditis, which was treated with pericardial window in an outside hospital, at that time she was also found to have mesenteric pain and thrombosis, is now anticoagulated. Her pericardial fluid was accumulated and she was seen by Dr. Y. At that time, she was recommended for pericardectomy, which was performed by Dr. Z. Review of her CT scan from March 2006 prior to her pericardectomy, already shows bilateral plural effusions. The patient improved clinically after the pericardectomy with resolution of her symptoms. Recently, she was readmitted to the hospital with chest pain and found to have bilateral pleural effusion, the right greater than the left. CT of the chest also revealed a large mediastinal lymph node. We reviewed the pathology obtained from the pericardectomy in March 2006, which was diagnostic of mesothelioma. At this time, chest tube placement for drainage of the fluid occurred and thoracoscopy with fluid biopsies, which were performed, which revealed epithelioid malignant mesothelioma. The patient was then stained with a PET CT, which showed extensive uptake in the chest, bilateral pleural pericardial effusions, and lymphadenopathy. She also had acidic fluid, pectoral and intramammary lymph nodes and uptake in L4 with SUV of 4. This was consistent with stage III disease. Her repeat echocardiogram showed an ejection fraction of 45% to 49%. She was transferred to Oncology service and started on chemotherapy on September 1, 2007 with cisplatin 75 mg/centimeter squared equaling 109 mg IV piggyback over 2 hours on September 1, 2007, Alimta 500 mg/ centimeter squared equaling 730 mg IV piggyback over 10 minutes. This was all initiated after a Port-A-Cath was placed. The chemotherapy was well tolerated and the patient was discharged the following day after discontinuing IV fluid and IV. Her Port-A-Cath was packed with heparin according to protocol.
DISCHARGE MEDICATIONS: Zofran, Phenergan, Coumadin, and Lovenox, and Vicodin
DISCHARGE INSTRUCTIONS: She was instructed to followup with Dr. XYZ in the office to check her INR on Tuesday. She was instructed to call if she had any other questions or concerns in the interim.
SECONDARY DIAGNOSES: Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.
PROCEDURES
1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.
2. On August 20, 2007, thoracentesis.
3. On August 31, 2007, Port-A-Cath placement.
HISTORY AND PHYSICAL: The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion.
PAST MEDICAL HISTORY
1. Pericardectomy.
2. Pericarditis.
2. Atrial fibrillation.
4. RNCA with intracranial thrombolytic treatment.
5 PTA of MCA.
6. Mesenteric venous thrombosis.
7. Pericardial window.
8. Cholecystectomy.
9. Left thoracentesis.
FAMILY HISTORY: No family history of coronary artery disease, CVA, diabetes, CHF or MI. The patient has one family member, a sister, with history of cancer.
SOCIAL HISTORY: She is married. Employed with the US Post Office. She is a mother of three. Denies tobacco, alcohol or illicit drug use.
MEDICATIONS
1. Coumadin 1 mg daily. Last INR was on Tuesday, August 14, 2007, and her INR was 2.3.
2. Amiodarone 100 mg p.o. daily.
REVIEW OF SYSTEMS: Complete review of systems negative except as in pulmonary as noted above. The patient also reports occasional numbness and tingling of her left arm.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 123/95, heart rate 83, respirations 20, temperature 97, and oxygen saturation 97%.
GENERAL: Positive nonproductive cough and pain with coughing.
HEENT: Pupils are equal and reactive to light and accommodation. Tympanic membranes are clear.
NECK: Supple. No lymphadenopathy. No masses.
RESPIRATORY: Pleural friction rub is noted.
GI: Soft, nondistended, and nontender. Positive bowel sounds. No organomegaly.
EXTREMITIES: No edema, no clubbing, no cyanosis, no tenderness. Full range of motion. Normal pulses in all extremities.
SKIN: No breakdown or lesions. No ulcers.
NEUROLOGIC: Grossly intact. No focal deficits. Awake, alert, and oriented to person, place, and time.
LABORATORY DATA: Labs are pending.
HOSPITAL COURSE: The patient was admitted for a right-sided pleural effusion for thoracentesis on Monday by Dr. X. Her Coumadin was placed on hold. A repeat echocardiogram was checked. She was started on prophylaxis for DVT with Lovenox 40 mg subcutaneously. Her history dated back to March 2005 when she first sought medical attention for evidence of pericarditis, which was treated with pericardial window in an outside hospital, at that time she was also found to have mesenteric pain and thrombosis, is now anticoagulated. Her pericardial fluid was accumulated and she was seen by Dr. Y. At that time, she was recommended for pericardectomy, which was performed by Dr. Z. Review of her CT scan from March 2006 prior to her pericardectomy, already shows bilateral plural effusions. The patient improved clinically after the pericardectomy with resolution of her symptoms. Recently, she was readmitted to the hospital with chest pain and found to have bilateral pleural effusion, the right greater than the left. CT of the chest also revealed a large mediastinal lymph node. We reviewed the pathology obtained from the pericardectomy in March 2006, which was diagnostic of mesothelioma. At this time, chest tube placement for drainage of the fluid occurred and thoracoscopy with fluid biopsies, which were performed, which revealed epithelioid malignant mesothelioma. The patient was then stained with a PET CT, which showed extensive uptake in the chest, bilateral pleural pericardial effusions, and lymphadenopathy. She also had acidic fluid, pectoral and intramammary lymph nodes and uptake in L4 with SUV of 4. This was consistent with stage III disease. Her repeat echocardiogram showed an ejection fraction of 45% to 49%. She was transferred to Oncology service and started on chemotherapy on September 1, 2007 with cisplatin 75 mg/centimeter squared equaling 109 mg IV piggyback over 2 hours on September 1, 2007, Alimta 500 mg/ centimeter squared equaling 730 mg IV piggyback over 10 minutes. This was all initiated after a Port-A-Cath was placed. The chemotherapy was well tolerated and the patient was discharged the following day after discontinuing IV fluid and IV. Her Port-A-Cath was packed with heparin according to protocol.
DISCHARGE MEDICATIONS: Zofran, Phenergan, Coumadin, and Lovenox, and Vicodin
DISCHARGE INSTRUCTIONS: She was instructed to followup with Dr. XYZ in the office to check her INR on Tuesday. She was instructed to call if she had any other questions or concerns in the interim.
Sample Name:
Disseminated Intravascular Coagulation
Description: Disseminated intravascular coagulation and Streptococcal
pneumonia with sepsis. Patient presented with symptoms of pneumonia and
developed rapid sepsis and respiratory failure requiring intubation.
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DIAGNOSES:
1. Disseminated intravascular coagulation.
2. Streptococcal pneumonia with sepsis.
CHIEF COMPLAINT: Unobtainable as the patient is intubated for respiratory failure.
CURRENT HISTORY OF PRESENT ILLNESS: This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.
PAST MEDICAL HISTORY: Otherwise nondescript as is the past surgical history.
SOCIAL HISTORY: There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.
FAMILY HISTORY: Otherwise noncontributory.
REVIEW OF SYSTEMS: Not otherwise pertinent.
PHYSICAL EXAMINATION:
GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated.
VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.
HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place.
NECK: No jugular venous pressure distention.
CHEST: Coarse breath sounds bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line.
EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.
LABORATORY STUDIES: The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.
IMPRESSION/PLAN: At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.
1. Disseminated intravascular coagulation.
2. Streptococcal pneumonia with sepsis.
CHIEF COMPLAINT: Unobtainable as the patient is intubated for respiratory failure.
CURRENT HISTORY OF PRESENT ILLNESS: This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.
PAST MEDICAL HISTORY: Otherwise nondescript as is the past surgical history.
SOCIAL HISTORY: There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.
FAMILY HISTORY: Otherwise noncontributory.
REVIEW OF SYSTEMS: Not otherwise pertinent.
PHYSICAL EXAMINATION:
GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated.
VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.
HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place.
NECK: No jugular venous pressure distention.
CHEST: Coarse breath sounds bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line.
EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.
LABORATORY STUDIES: The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.
IMPRESSION/PLAN: At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.
Sample Name:
Endometrial Cancer Followup
Description: Stage IIIC endometrial cancer. Adjuvant chemotherapy with
cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who
was noted to have abnormal vaginal bleeding in the fall of 2009.
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CHIEF COMPLAINT:
1. Stage IIIC endometrial cancer.
2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.
CURRENT MEDICATIONS: Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: The patient reports feeling weaker after this last cycle. She continues to have neuropathy in her feet recorded as a great line neuropathy. She tried taking two gabapentin for the neuropathy made her nauseous and somnolent. She does much better with one tablet. Her family noticed hearing problems. She was a due to have a hearing test on 08/04/10 but had to reschedule. She was out of town. The patient personally does not note problems with her hearing. She denies any fevers, chills, or night sweats, chest pain, or shortness of breath. The rest of her review of system is negative.
PHYSICAL EXAM:
VITALS: BP: 100/56. HEART RATE: 84. TEMP: 97.8. Weight: 75 kg.
GEN: She has patchy alopecia.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is clear. She has no stomatitis.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly.
EXT: Lower extremities are without edema.
SKIN: She has no skin rash.
LABORATORY DATA: White blood cell count is 5.3, hemoglobin 11, hematocrit 32.2, and platelets 273,000. Sodium 137, potassium 3.4, chloride 105, CO2 24, BUN 12, creatinine 0.75, glucose 144, calcium 9.4, total protein 7.5, albumin 3.9, total bilirubin 0.4, alkaline phosphatase 67, AST 33, ALT 23, magnesium 1.9, CEA 1257.
ASSESSMENT/PLAN: This is a very pleasant 47-year-old female with stage IIIC adenocarcinoma of the endometrial cancer. She has completed five of a planned six cycles of chemotherapy with doxorubicin, cisplatin, and Abraxane. She is slightly anemic after this last treatment and is feeling weaker. Most of this is cumulative effects of treatment. She is experiencing some neuropathy. With the Abraxane we tend to see more intensive neuropathy during treatment with improved resolution once treatment is completed. Her chemotherapy toxicities remain minimal. We will plan to proceed with cycle #6. I will see her back in the clinic after the sixth cycle. We will plan to repeat PET/CT scan about a month after she completes her sixth cycle and then she will followup with Dr. X in radiation oncology to further discuss radiation options.
1. Stage IIIC endometrial cancer.
2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.
CURRENT MEDICATIONS: Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: The patient reports feeling weaker after this last cycle. She continues to have neuropathy in her feet recorded as a great line neuropathy. She tried taking two gabapentin for the neuropathy made her nauseous and somnolent. She does much better with one tablet. Her family noticed hearing problems. She was a due to have a hearing test on 08/04/10 but had to reschedule. She was out of town. The patient personally does not note problems with her hearing. She denies any fevers, chills, or night sweats, chest pain, or shortness of breath. The rest of her review of system is negative.
PHYSICAL EXAM:
VITALS: BP: 100/56. HEART RATE: 84. TEMP: 97.8. Weight: 75 kg.
GEN: She has patchy alopecia.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is clear. She has no stomatitis.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly.
EXT: Lower extremities are without edema.
SKIN: She has no skin rash.
LABORATORY DATA: White blood cell count is 5.3, hemoglobin 11, hematocrit 32.2, and platelets 273,000. Sodium 137, potassium 3.4, chloride 105, CO2 24, BUN 12, creatinine 0.75, glucose 144, calcium 9.4, total protein 7.5, albumin 3.9, total bilirubin 0.4, alkaline phosphatase 67, AST 33, ALT 23, magnesium 1.9, CEA 1257.
ASSESSMENT/PLAN: This is a very pleasant 47-year-old female with stage IIIC adenocarcinoma of the endometrial cancer. She has completed five of a planned six cycles of chemotherapy with doxorubicin, cisplatin, and Abraxane. She is slightly anemic after this last treatment and is feeling weaker. Most of this is cumulative effects of treatment. She is experiencing some neuropathy. With the Abraxane we tend to see more intensive neuropathy during treatment with improved resolution once treatment is completed. Her chemotherapy toxicities remain minimal. We will plan to proceed with cycle #6. I will see her back in the clinic after the sixth cycle. We will plan to repeat PET/CT scan about a month after she completes her sixth cycle and then she will followup with Dr. X in radiation oncology to further discuss radiation options.
Sample Name:
Excision of Squamous Cell Carcinoma
Description: Re-excision of squamous cell carcinoma site, right hand.
(Medical Transcription Sample Report)
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PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma on the right hand, incompletely
excised.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma on the right hand, incompletely excised.
NAME OF OPERATION: Re-excision of squamous cell carcinoma site, right hand.
ANESTHESIA: Local with monitored anesthesia care.
INDICATIONS: Patient, 72, status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb. The deep margin was positive. Other margins were clear. He was brought back for re-excision.
PROCEDURE: The patient was brought to the operating room and placed in the supine position. He was given intravenous sedation. The right hand was prepped and draped in the usual sterile fashion. Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath. The tissue was passed off the field as a specimen.
The wound was irrigated with warm normal saline. Hemostasis was assured with the electrocautery. The wound was closed with running 3-0 nylon without complication. The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma on the right hand, incompletely excised.
NAME OF OPERATION: Re-excision of squamous cell carcinoma site, right hand.
ANESTHESIA: Local with monitored anesthesia care.
INDICATIONS: Patient, 72, status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb. The deep margin was positive. Other margins were clear. He was brought back for re-excision.
PROCEDURE: The patient was brought to the operating room and placed in the supine position. He was given intravenous sedation. The right hand was prepped and draped in the usual sterile fashion. Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath. The tissue was passed off the field as a specimen.
The wound was irrigated with warm normal saline. Hemostasis was assured with the electrocautery. The wound was closed with running 3-0 nylon without complication. The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.
Sample Name:
Eyelid Squamous Cell Carcinoma Excision
Description: Excision of right upper eyelid squamous cell carcinoma with
frozen section and full-thickness skin grafting from the opposite eyelid.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right upper eyelid squamous cell carcinoma.
POSTOPERATIVE DIAGNOSIS: Right upper eyelid squamous cell carcinoma.
PROCEDURE PERFORMED: Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.
COMPLICATIONS: None.
BLOOD LOSS: Minimal.
ANESTHESIA: Local with sedation.
INDICATION: The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids. The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.
POSTOPERATIVE DIAGNOSIS: Right upper eyelid squamous cell carcinoma.
PROCEDURE PERFORMED: Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.
COMPLICATIONS: None.
BLOOD LOSS: Minimal.
ANESTHESIA: Local with sedation.
INDICATION: The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids. The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.
Sample Name:
Glioblastoma Multiforme - Consult
Description: Asked to see the patient in regards to a brain tumor. She
was initially diagnosed with a glioblastoma multiforme. She presented with
several lesions in her brain and a biopsy confirmed the diagnosis.
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REASON FOR CONSULTATION: We were asked to see the patient in regards to a brain
tumor.
HISTORY OF PRESENT ILLNESS: She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our group. Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department. Details of her treatment are not available at the time of this dictation. Her family has a packet of Temodar 100-mg pills. She is admitted now with increasing confusion. A CT shows increase in size of the lesions compared to the preoperative scan. We are asked to comment on her treatment at this point. She herself is confused and is unable to provide further history.
PAST MEDICAL HISTORY: From her old chart: No known past medical history prior to the diagnosis.
SOCIAL HISTORY: She was living alone and is now living in assisted living.
MEDICATIONS
1. Dilantin 300 mg daily.
2. Haloperidol 1 mg h.s.
3. Dexamethasone 4 mg q.i.d.
4. Docusate 100 mg b.i.d.
5. Pen-VK 500 mg daily.
6. Ibuprofen 600 mg daily.
7. Zantac 150 mg twice a day.
8. Temodar 100 mg daily.
9. Magic Mouthwash daily.
10. Tylenol #3 as needed.
REVIEW OF SYSTEMS: Unable.
PHYSICAL EXAMINATION
GENERAL: Elderly woman, confused.
HEENT: Normal conjunctivae. Ears and nose normal. Mouth normal.
NECK: Supple.
CHEST: Clear.
HEART: Normal.
ABDOMEN: Soft, positive bowel sounds.
NEUROLOGIC: Alert, cranial nerves intact. Left arm slightly weak. Left leg slightly weak.
IMPRESSION AND PLAN: Glioblastoma multiforme, uncertain as to where she is in cancer treatment. Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor. We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen. At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
HISTORY OF PRESENT ILLNESS: She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our group. Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department. Details of her treatment are not available at the time of this dictation. Her family has a packet of Temodar 100-mg pills. She is admitted now with increasing confusion. A CT shows increase in size of the lesions compared to the preoperative scan. We are asked to comment on her treatment at this point. She herself is confused and is unable to provide further history.
PAST MEDICAL HISTORY: From her old chart: No known past medical history prior to the diagnosis.
SOCIAL HISTORY: She was living alone and is now living in assisted living.
MEDICATIONS
1. Dilantin 300 mg daily.
2. Haloperidol 1 mg h.s.
3. Dexamethasone 4 mg q.i.d.
4. Docusate 100 mg b.i.d.
5. Pen-VK 500 mg daily.
6. Ibuprofen 600 mg daily.
7. Zantac 150 mg twice a day.
8. Temodar 100 mg daily.
9. Magic Mouthwash daily.
10. Tylenol #3 as needed.
REVIEW OF SYSTEMS: Unable.
PHYSICAL EXAMINATION
GENERAL: Elderly woman, confused.
HEENT: Normal conjunctivae. Ears and nose normal. Mouth normal.
NECK: Supple.
CHEST: Clear.
HEART: Normal.
ABDOMEN: Soft, positive bowel sounds.
NEUROLOGIC: Alert, cranial nerves intact. Left arm slightly weak. Left leg slightly weak.
IMPRESSION AND PLAN: Glioblastoma multiforme, uncertain as to where she is in cancer treatment. Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor. We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen. At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
Sample Name:
HDR Brachytherapy
Description: HDR Brachytherapy
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HDR BRACHYTHERAPY
The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. Simulation films were obtained, documenting its positioning. The 3-dimensional treatment planning process was accomplished utilizing the CT derived data. A treatment plan was selected utilizing sequential dwell positions within a single catheter. The patient was taken to the treatment area. The patient was appropriately positioned and the position of the intracavitary device was checked. Catheter length measurements were taken. Appropriate measurements of the probe dimensions and assembly were also performed. The applicator was attached to the HDR after-loader device. The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication. The brachytherapy source was appropriately removed back to the brachytherapy safe within the device. Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.
Following completion of the procedure, the intracavitary device was removed without difficulty. The patient was in no apparent distress and was discharged home.
The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. Simulation films were obtained, documenting its positioning. The 3-dimensional treatment planning process was accomplished utilizing the CT derived data. A treatment plan was selected utilizing sequential dwell positions within a single catheter. The patient was taken to the treatment area. The patient was appropriately positioned and the position of the intracavitary device was checked. Catheter length measurements were taken. Appropriate measurements of the probe dimensions and assembly were also performed. The applicator was attached to the HDR after-loader device. The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication. The brachytherapy source was appropriately removed back to the brachytherapy safe within the device. Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.
Following completion of the procedure, the intracavitary device was removed without difficulty. The patient was in no apparent distress and was discharged home.
Sample Name:
Head & Neck Cancer Consult
Description: Newly diagnosed head and neck cancer. The patient was
recently diagnosed with squamous cell carcinoma of the base of the tongue
bilaterally and down extension into the right tonsillar fossa.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Newly diagnosed head and neck cancer.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. He was also noted to have palpable level 2 cervical lymph nodes. His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck. The patient comes in to the clinic today after radiation Oncology consultation. His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010. The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain. He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease. His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia. He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa. He was noted to have bilateral neck nodes. His biopsy was positive for squamous cell carcinoma.
PAST MEDICAL HISTORY: Significant for mild hypertension. He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.
ALLERGIES: Penicillin.
CURRENT MEDICATIONS: Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.
FAMILY HISTORY: Significant for father who has stroke and grandfather with lung cancer.
SOCIAL HISTORY: The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons. He is retired from the Air Force, currently works for Lockheed Martin. He was born and raised in New York. He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27. He does drink alcohol socially. No use of illicit drugs.
REVIEW OF SYSTEMS: The patient's chief complaint is fatigue. He has difficulty swallowing and dysphagia. He is responding well to Lortab and Tylenol for pain control. He denies any chest pain, shortness of breath, fevers, chills and night sweats. The rest of his review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 115/70. HEART RATE: 62. TEMP: 97.4. Weight: 93.6 kg.
GEN: He is very pleasant and in no acute distress. He has noticeable mass on his left neck.
HEENT: Pupils are equal, round, and reactive to light. Sclerae anicteric. His oropharynx is notable for scalloped tongue and he has no oral ulcers. Upon protrusion of his tongue, he has deviation to the right.
NECK: Noticeable for bilateral palpable adenopathy with a large palpable mass in the left neck.
LUNGS: Clear to auscultation on the right. He has some mild vesicular breath sounds in the left.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. No axillary inguinal adenopathy.
EXT: No lower extremity edema.
LABORATORY STUDIES:
1. A PET/CT scan shows a large hypermetabolic mass involved in the posterior aspect of the tongue, which is predominantly right-sided but extends across the midline to involve the right posterior aspect of the tongue as well.
2. Extensive bulky hypermetabolic cervical lymphadenopathy bilaterally.
3. No evidence of distant hypermetabolic metastatic disease.
4. His biopsy of the right base of the tongue, invasive squamous cell carcinoma. Biopsy of the left base of the tongue, invasive squamous cell carcinoma moderately differentiated.
ASSESSMENT/PLAN: This is a pleasant but unfortunate 61-year-old gentleman who was diagnosed with stage IV, a squamous cell carcinoma of the oropharynx. He has met with radiation oncology to discuss the plan and he has also been in close contact with his dentist. He has a known abscess and is in need of some bridge work. I discussed issues with his dentist and the patient will be seeing this Friday for cleaning. One of the things that we will need to coordinate is evaluation of the involvement of his salivary glands. There needs to be a discussion as to whether or not he would be better off with the tooth extraction prior to radiation. We will coordinate this between myself, radiation oncology, and his dentist.
As far as his chemotherapy treatment, the plan at this point is to proceed with two cycles of induction chemotherapy. The first cycle will include docetaxel, cisplatin and 5-fluorouracil plus Erbitux. Typical administration is docetaxel, cisplatin and 5-fluorouracil on day 1 with continuous infusion of 5-fluorouracil through day 4. Erbitux will be administered on day 1 and day 8 of the first cycle. We will plan to proceed with the second cycle to include docetaxel, cisplatin and continuous infusion of 5-fluorouracil without the Erbitux. Following induction chemotherapy, we plan to obtain a PET/CT scan. Again, this will be closely coordinated with radiation onset if they can do with planning CT at that time of the PET. Radiation will be planned with concurrent Erbitux. This will be given, the first dose will be one week prior to starting the radiation and then given weekly throughout radiation. I did discuss briefly with the patient the possibility of admission for the induction chemotherapy. The patient was not very excited at this particular discussion. Otherwise, I do feel with him living in the Longmont area that this may be our best bet and would also be a way of being able to closely monitor his kidney function and administer the necessary hydration. He is scheduled for chemo education on August 16. He received prescription refill for Lortab for pain management, and I will see him in clinic when he comes in for chemotherapy education so that we can talk further about treatment administration. I appreciate the consultation.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. He was also noted to have palpable level 2 cervical lymph nodes. His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck. The patient comes in to the clinic today after radiation Oncology consultation. His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010. The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain. He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease. His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia. He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa. He was noted to have bilateral neck nodes. His biopsy was positive for squamous cell carcinoma.
PAST MEDICAL HISTORY: Significant for mild hypertension. He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.
ALLERGIES: Penicillin.
CURRENT MEDICATIONS: Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.
FAMILY HISTORY: Significant for father who has stroke and grandfather with lung cancer.
SOCIAL HISTORY: The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons. He is retired from the Air Force, currently works for Lockheed Martin. He was born and raised in New York. He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27. He does drink alcohol socially. No use of illicit drugs.
REVIEW OF SYSTEMS: The patient's chief complaint is fatigue. He has difficulty swallowing and dysphagia. He is responding well to Lortab and Tylenol for pain control. He denies any chest pain, shortness of breath, fevers, chills and night sweats. The rest of his review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 115/70. HEART RATE: 62. TEMP: 97.4. Weight: 93.6 kg.
GEN: He is very pleasant and in no acute distress. He has noticeable mass on his left neck.
HEENT: Pupils are equal, round, and reactive to light. Sclerae anicteric. His oropharynx is notable for scalloped tongue and he has no oral ulcers. Upon protrusion of his tongue, he has deviation to the right.
NECK: Noticeable for bilateral palpable adenopathy with a large palpable mass in the left neck.
LUNGS: Clear to auscultation on the right. He has some mild vesicular breath sounds in the left.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. No axillary inguinal adenopathy.
EXT: No lower extremity edema.
LABORATORY STUDIES:
1. A PET/CT scan shows a large hypermetabolic mass involved in the posterior aspect of the tongue, which is predominantly right-sided but extends across the midline to involve the right posterior aspect of the tongue as well.
2. Extensive bulky hypermetabolic cervical lymphadenopathy bilaterally.
3. No evidence of distant hypermetabolic metastatic disease.
4. His biopsy of the right base of the tongue, invasive squamous cell carcinoma. Biopsy of the left base of the tongue, invasive squamous cell carcinoma moderately differentiated.
ASSESSMENT/PLAN: This is a pleasant but unfortunate 61-year-old gentleman who was diagnosed with stage IV, a squamous cell carcinoma of the oropharynx. He has met with radiation oncology to discuss the plan and he has also been in close contact with his dentist. He has a known abscess and is in need of some bridge work. I discussed issues with his dentist and the patient will be seeing this Friday for cleaning. One of the things that we will need to coordinate is evaluation of the involvement of his salivary glands. There needs to be a discussion as to whether or not he would be better off with the tooth extraction prior to radiation. We will coordinate this between myself, radiation oncology, and his dentist.
As far as his chemotherapy treatment, the plan at this point is to proceed with two cycles of induction chemotherapy. The first cycle will include docetaxel, cisplatin and 5-fluorouracil plus Erbitux. Typical administration is docetaxel, cisplatin and 5-fluorouracil on day 1 with continuous infusion of 5-fluorouracil through day 4. Erbitux will be administered on day 1 and day 8 of the first cycle. We will plan to proceed with the second cycle to include docetaxel, cisplatin and continuous infusion of 5-fluorouracil without the Erbitux. Following induction chemotherapy, we plan to obtain a PET/CT scan. Again, this will be closely coordinated with radiation onset if they can do with planning CT at that time of the PET. Radiation will be planned with concurrent Erbitux. This will be given, the first dose will be one week prior to starting the radiation and then given weekly throughout radiation. I did discuss briefly with the patient the possibility of admission for the induction chemotherapy. The patient was not very excited at this particular discussion. Otherwise, I do feel with him living in the Longmont area that this may be our best bet and would also be a way of being able to closely monitor his kidney function and administer the necessary hydration. He is scheduled for chemo education on August 16. He received prescription refill for Lortab for pain management, and I will see him in clinic when he comes in for chemotherapy education so that we can talk further about treatment administration. I appreciate the consultation.
Sample Name:
Hematology Consult
Description: Leukocytosis, acute deep venous thrombosis, right lower
extremity with bilateral pulmonary embolism, on intravenous heparin complicated
with acute renal failure for evaluation.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Acute deep venous thrombosis, right lower extremity with
bilateral pulmonary embolism, on intravenous heparin complicated with acute
renal failure for evaluation.
HISTORY OF PRESENTING ILLNESS: Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital. A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism. A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis. A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct. Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today. He has been on intravenous heparin and hemodialysis is being planned for tomorrow. Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication. He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.
PAST MEDICAL AND SURGICAL HISTORY: Unremarkable.
SOCIAL HISTORY: He is married and has 1 son. He has a brother who is healthy. There is no history of tobacco use or alcohol use.
FAMILY HISTORY: No family history of hypercoagulable condition.
MEDICATIONS: Advil p.r.n.
ALLERGIES: NONE.
REVIEW OF SYSTEMS: Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope. He denied any hemoptysis. He denied any calf swelling or pain. Lately, he has been traveling and has been sitting behind a desk for a long period of time.
PHYSICAL EXAMINATION:
GENERAL: He is a robust young gentleman, awake, alert, and hemodynamically stable.
HEENT: Sclerae anicteric. Conjunctivae normal. Oropharynx normal.
NECK: No adenopathy or thyromegaly. No jugular venous distention.
HEART: Regular.
LUNGS: Bilateral air entry.
ABDOMEN: Obese and benign.
EXTREMITIES: No calf swelling or calf tenderness appreciated.
SKIN: No petechiae or ecchymosis.
NEUROLOGIC: Nonfocal.
LABORATORY FINDINGS: Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000. Liver profile normal. Thyroid study revealed a TSH of 1.3. Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds. Renal function, BUN 44 and creatinine 5.7. Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.
IMPRESSION:
1. Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.
2. Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.
3. Acute renal failure secondary to embolic right renal infarction.
4. Obesity.
PLAN: From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play. For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin. In view of worsening renal function, may need temporary hemodialysis until renal function improves. I discussed at length with the patient's wife at the bedside.
HISTORY OF PRESENTING ILLNESS: Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital. A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism. A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis. A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct. Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today. He has been on intravenous heparin and hemodialysis is being planned for tomorrow. Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication. He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.
PAST MEDICAL AND SURGICAL HISTORY: Unremarkable.
SOCIAL HISTORY: He is married and has 1 son. He has a brother who is healthy. There is no history of tobacco use or alcohol use.
FAMILY HISTORY: No family history of hypercoagulable condition.
MEDICATIONS: Advil p.r.n.
ALLERGIES: NONE.
REVIEW OF SYSTEMS: Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope. He denied any hemoptysis. He denied any calf swelling or pain. Lately, he has been traveling and has been sitting behind a desk for a long period of time.
PHYSICAL EXAMINATION:
GENERAL: He is a robust young gentleman, awake, alert, and hemodynamically stable.
HEENT: Sclerae anicteric. Conjunctivae normal. Oropharynx normal.
NECK: No adenopathy or thyromegaly. No jugular venous distention.
HEART: Regular.
LUNGS: Bilateral air entry.
ABDOMEN: Obese and benign.
EXTREMITIES: No calf swelling or calf tenderness appreciated.
SKIN: No petechiae or ecchymosis.
NEUROLOGIC: Nonfocal.
LABORATORY FINDINGS: Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000. Liver profile normal. Thyroid study revealed a TSH of 1.3. Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds. Renal function, BUN 44 and creatinine 5.7. Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.
IMPRESSION:
1. Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.
2. Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.
3. Acute renal failure secondary to embolic right renal infarction.
4. Obesity.
PLAN: From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play. For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin. In view of worsening renal function, may need temporary hemodialysis until renal function improves. I discussed at length with the patient's wife at the bedside.
Hematology -
Oncology
Sample Name: Hyperfractionation
Sample Name: Hyperfractionation
Description: Hyperfractionation. This patient is to undergo a course of
hyperfractionated radiotherapy in the treatment of known malignancy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HYPERFRACTIONATION
This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors. The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.
During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.
This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors. The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.
During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.
Sample Name:
Intensity-Modulated Radiation Therapy
Description: Intensity-modulated radiation therapy is a complex set of
procedures which requires appropriate positioning and immobilization typically
with customized immobilization devices.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INTENSITY-MODULATED RADIATION
THERAPY
Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.
In view of the above, the special procedure code 77470 is deemed appropriate.
Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.
In view of the above, the special procedure code 77470 is deemed appropriate.
Sample Name:
Intensity-Modulated Radiation Therapy Simulation
Description: Intensity-modulated radiation therapy simulation note. The
patient will receive intensity-modulated radiation therapy in order to deliver
high-dose treatment to sensitive structures.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
INTENSITY-MODULATED RADIATION THERAPY
SIMULATION
The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. The target volume is adjacent to significant radiosensitive structures.
Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit. The patient is appropriately immobilized using a customized immobilization device. Preliminary simulation films are obtained and approved by me. The patient is marked and transferred to the CT scanner. Sequential images are obtained and transferred electronically to the treatment planning software. Extensive analysis then occurs. The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition organs at risk are outlined. Appropriate doses are selected, both for the target, as well as constraints for organs at risk. Inverse treatment planning is performed by the physics staff under my supervision. These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.
The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. The target volume is adjacent to significant radiosensitive structures.
Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit. The patient is appropriately immobilized using a customized immobilization device. Preliminary simulation films are obtained and approved by me. The patient is marked and transferred to the CT scanner. Sequential images are obtained and transferred electronically to the treatment planning software. Extensive analysis then occurs. The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition organs at risk are outlined. Appropriate doses are selected, both for the target, as well as constraints for organs at risk. Inverse treatment planning is performed by the physics staff under my supervision. These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.
Sample Name:
Intraperitoneal Mesothelioma
Description: A female with a history of peritoneal mesothelioma who has
received prior intravenous chemotherapy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR ADMISSION: Intraperitoneal chemotherapy.
HISTORY: A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma. The patient has received prior intravenous chemotherapy. Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy. She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her. Therefore, on the last hospitalization for IP chemo, she was switched to Taxol. The patient since her last visit has done relatively well. She had no acute problems and has basically only chronic difficulties. She has had some decrease in her appetite, although her weight has been stable. She has had no fever, chills, or sweats. Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease. She had a recent CT scan of the chest and abdomen. The report showed the following findings. In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve. There was one mildly enlarged mediastinal lymph node. Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific. No pulmonary masses were noted. In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland. On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted. There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study. A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst. It was unchanged from February and measured 9 mm. There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable. Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them. There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm. In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter. No suspicious osseous lesions were noted.
CURRENT MEDICATIONS: Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.
ALLERGIES: THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.
PHYSICAL EXAMINATION
VITAL SIGNS: The patient's height is 165 cm, weight is 77 kg. BSA is 1.8 sq m. The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.
GENERAL: She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time. She is anicteric.
HEENT: EOM is full. Pupils are equal, round, reactive to light and accommodation. Disc margins are unremarkable as are the ocular fields. Mouth and pharynx within normal limits. The TMs are glistening bilaterally. External auditory canals are unremarkable.
NECK: Supple, nontender without adenopathy. Trachea is midline. There are no bruits nor is there jugular venous distention.
CHEST: Clear to percussion and auscultation bilaterally.
HEART: Regular rate and rhythm without murmur, gallop, or rub.
BREASTS: Unremarkable.
ABDOMEN: Slightly protuberant. Bowel tones are present and normal. She has no palpable mass, and there is no hepatosplenomegaly.
EXTREMITIES: Within normal limits.
NEUROLOGICAL: Nonfocal.
DIAGNOSTIC IMPRESSION
1. Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.
2. Presumed left lower pole kidney hemorrhagic cyst.
3. History of hypertension.
4. Type 1 bipolar disease.
PLAN: The patient will have appropriate laboratory studies done. A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney. Interventional radiology will access for ports in the abdomen. She will receive chemotherapy intraperitoneally. The plan will be to use intraperitoneal Taxol.
HISTORY: A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma. The patient has received prior intravenous chemotherapy. Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy. She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her. Therefore, on the last hospitalization for IP chemo, she was switched to Taxol. The patient since her last visit has done relatively well. She had no acute problems and has basically only chronic difficulties. She has had some decrease in her appetite, although her weight has been stable. She has had no fever, chills, or sweats. Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease. She had a recent CT scan of the chest and abdomen. The report showed the following findings. In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve. There was one mildly enlarged mediastinal lymph node. Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific. No pulmonary masses were noted. In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland. On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted. There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study. A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst. It was unchanged from February and measured 9 mm. There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable. Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them. There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm. In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter. No suspicious osseous lesions were noted.
CURRENT MEDICATIONS: Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.
ALLERGIES: THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.
PHYSICAL EXAMINATION
VITAL SIGNS: The patient's height is 165 cm, weight is 77 kg. BSA is 1.8 sq m. The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.
GENERAL: She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time. She is anicteric.
HEENT: EOM is full. Pupils are equal, round, reactive to light and accommodation. Disc margins are unremarkable as are the ocular fields. Mouth and pharynx within normal limits. The TMs are glistening bilaterally. External auditory canals are unremarkable.
NECK: Supple, nontender without adenopathy. Trachea is midline. There are no bruits nor is there jugular venous distention.
CHEST: Clear to percussion and auscultation bilaterally.
HEART: Regular rate and rhythm without murmur, gallop, or rub.
BREASTS: Unremarkable.
ABDOMEN: Slightly protuberant. Bowel tones are present and normal. She has no palpable mass, and there is no hepatosplenomegaly.
EXTREMITIES: Within normal limits.
NEUROLOGICAL: Nonfocal.
DIAGNOSTIC IMPRESSION
1. Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.
2. Presumed left lower pole kidney hemorrhagic cyst.
3. History of hypertension.
4. Type 1 bipolar disease.
PLAN: The patient will have appropriate laboratory studies done. A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney. Interventional radiology will access for ports in the abdomen. She will receive chemotherapy intraperitoneally. The plan will be to use intraperitoneal Taxol.
Sample Name:
Iron deficiency anemia
Description: Iron deficiency anemia. She underwent a bone marrow biopsy
which showed a normal cellular marrow with trilineage hematopoiesis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Iron deficiency anemia.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis. On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells. Her iron levels were 5 and her percent transferrin was 2. There was no evidence of hemolysis. Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth. She currently has an IUD, so she is not menstruating. She was discharged from the hospital on iron supplements. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. She specifically denies melena or hematochezia.
CURRENT MEDICATIONS: Iron supplements and Levaquin.
ALLERGIES: Penicillin.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY: She is status post birth of a baby girl 5 months ago. She is G1, P1. She is currently using an IUD for contraception.
SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. No illicit drug use.
FAMILY HISTORY: Her maternal grandmother had stomach cancer. There is no history of hematologic malignancies.
PHYSICAL EXAM:
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Iron deficiency anemia. At this point, I am going to schedule her for an EGD and a colonscopy. I am also going to repeat her iron studies. She had a CBC from yesterday, which showed hemoglobin of 10.4. Her MCV was still low at 74.2 and the mean cell hemoglobin was 25.0. I would also like to check her fecal occult blood test x3. I believe with her low iron levels it is going to be very difficult for her to replace it orally. I believe she may need intravenous iron infusions. If that is case, we can arrange for her to find a doctor who can give the iron infusions. She will follow up with Dr. X.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis. On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells. Her iron levels were 5 and her percent transferrin was 2. There was no evidence of hemolysis. Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth. She currently has an IUD, so she is not menstruating. She was discharged from the hospital on iron supplements. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. She specifically denies melena or hematochezia.
CURRENT MEDICATIONS: Iron supplements and Levaquin.
ALLERGIES: Penicillin.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY: She is status post birth of a baby girl 5 months ago. She is G1, P1. She is currently using an IUD for contraception.
SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. No illicit drug use.
FAMILY HISTORY: Her maternal grandmother had stomach cancer. There is no history of hematologic malignancies.
PHYSICAL EXAM:
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Iron deficiency anemia. At this point, I am going to schedule her for an EGD and a colonscopy. I am also going to repeat her iron studies. She had a CBC from yesterday, which showed hemoglobin of 10.4. Her MCV was still low at 74.2 and the mean cell hemoglobin was 25.0. I would also like to check her fecal occult blood test x3. I believe with her low iron levels it is going to be very difficult for her to replace it orally. I believe she may need intravenous iron infusions. If that is case, we can arrange for her to find a doctor who can give the iron infusions. She will follow up with Dr. X.
Sample Name:
Leiomyosarcoma
Description: Discharge summary of patient with leiomyosarcoma and history
of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
ADMITTING DIAGNOSES:
1. Leiomyosarcoma.
2. History of pulmonary embolism.
3. History of subdural hematoma.
4. Pancytopenia.
5. History of pneumonia.
PROCEDURES DURING HOSPITALIZATION:
1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.
2. CTA, chest PE study showing no evidence for pulmonary embolism.
3. Head CT showing no evidence of acute intracranial abnormalities.
4. Sinus CT, normal mini-CT of the paranasal sinuses.
HISTORY OF PRESENT ILLNESS: Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007. The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon. MRI showed inflammation and was thought to be secondary to rheumatoid arthritis. The mass increased in size. She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive. She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy. She began treatment with CIVI-CAD in December 2007. Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation. She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.
HOSPITAL COURSE:
1. Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.
2. History of pulmonary embolism. Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain. She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day. She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.
3. History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own. Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities. The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.
4. Pancytopenia. On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400. The patient's counts were followed throughout admission. She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet. At discharge her ANC is back up to 1100 and she is taken off neutropenic diet. Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.
5. History of pneumonia. During admission, the patient did not exhibit any signs or symptoms of pneumonia.
DISPOSITION: Home in stable condition.
DIET: Regular and less neutropenic.
ACTIVITY: Resume same activity.
FOLLOWUP: The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m. The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.
1. Leiomyosarcoma.
2. History of pulmonary embolism.
3. History of subdural hematoma.
4. Pancytopenia.
5. History of pneumonia.
PROCEDURES DURING HOSPITALIZATION:
1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.
2. CTA, chest PE study showing no evidence for pulmonary embolism.
3. Head CT showing no evidence of acute intracranial abnormalities.
4. Sinus CT, normal mini-CT of the paranasal sinuses.
HISTORY OF PRESENT ILLNESS: Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007. The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon. MRI showed inflammation and was thought to be secondary to rheumatoid arthritis. The mass increased in size. She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive. She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy. She began treatment with CIVI-CAD in December 2007. Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation. She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.
HOSPITAL COURSE:
1. Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.
2. History of pulmonary embolism. Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain. She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day. She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.
3. History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own. Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities. The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.
4. Pancytopenia. On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400. The patient's counts were followed throughout admission. She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet. At discharge her ANC is back up to 1100 and she is taken off neutropenic diet. Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.
5. History of pneumonia. During admission, the patient did not exhibit any signs or symptoms of pneumonia.
DISPOSITION: Home in stable condition.
DIET: Regular and less neutropenic.
ACTIVITY: Resume same activity.
FOLLOWUP: The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m. The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.
Sample Name:
Lung Cancer & MI - Hospice Cosult
Description: Patient with metastatic non-small-cell lung cancer, on
hospice with inferior ST-elevation MI. The patient from prior strokes has
expressive aphasia, is not able to express herself in a clear meaningful
fashion.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULT: I was asked to see this patient with metastatic
non-small-cell lung cancer, on hospice with inferior ST-elevation MI.
HISTORY OF PRESENT ILLNESS: The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.
She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.
PAST MEDICAL HISTORY: Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.
MEDICATIONS: Medications as an outpatient:
1. Amiodarone 200 mg once a day.
2. Roxanol concentrate 5 mg three hours p.r.n. pain.
ALLERGIES: CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.
FAMILY HISTORY: Negative for cardiac disease.
SOCIAL HISTORY: She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.
REVIEW OF SYSTEMS: Unable to be obtained due to the patient's aphasia.
PHYSICAL EXAMINATION: Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.
DIAGNOSTIC/LABORATORY DATA: EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.
Chest x-ray, no significant pericardial effusion.
IMPRESSION: The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.
RECOMMENDATIONS:
1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.
2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.
3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.
Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.
HISTORY OF PRESENT ILLNESS: The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.
She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.
PAST MEDICAL HISTORY: Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.
MEDICATIONS: Medications as an outpatient:
1. Amiodarone 200 mg once a day.
2. Roxanol concentrate 5 mg three hours p.r.n. pain.
ALLERGIES: CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.
FAMILY HISTORY: Negative for cardiac disease.
SOCIAL HISTORY: She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.
REVIEW OF SYSTEMS: Unable to be obtained due to the patient's aphasia.
PHYSICAL EXAMINATION: Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.
DIAGNOSTIC/LABORATORY DATA: EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.
Chest x-ray, no significant pericardial effusion.
IMPRESSION: The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.
RECOMMENDATIONS:
1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.
2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.
3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.
Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.
Hematology -
Oncology
Sample Name: Lung Cancer Followup
Sample Name: Lung Cancer Followup
Description: Extensive stage small cell lung cancer. Chemotherapy with
carboplatin and etoposide. Left scapular pain status post CT scan of the
thorax.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT:
1. Extensive stage small cell lung cancer.
2. Chemotherapy with carboplatin and etoposide.
3. Left scapular pain status post CT scan of the thorax.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with carboplatin and etoposide. She completed her fifth cycle on 08/12/10. She has had ongoing back pain and was sent for a CT scan of the thorax. She comes into clinic today accompanied by her daughters to review the results.
CURRENT MEDICATIONS: Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: The patient continues to have back pain some time she also take two pain pill. She received platelet transfusion the other day and reported mild fever. She denies any chills, night sweats, chest pain, or shortness of breath. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 118/60. HEART RATE: 76. TEMP: 97.8. Weight: 65.5 kg.
GEN: She looks well, in no acute distress.
HEENT: Her pupils were noted for surgical changes bilaterally. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds.
EXT: Lower extremities are without edema.
IMAGING: Her CT scan shows a pleural base mass in the left apex appears to have some growth along the medial margin comparing with PET/CT assessment 07/08/10. While this extends to the pleural surface it does not clearly invade directly into the chest wall or the adjacent posterior lateral left third rib. Left suprahilar and mediastinal adenopathy appears to be essentially stable since 07/08/10. Multilevel thoracic bony metastatic disease is present. Hypodense liver metastasis appears slightly improved comparing with July, more substantially improved comparing with chest CT of 04/21/10.
ASSESSMENT/PLAN: This is a very pleasant female 67-year-old female with extensive stage small cell lung cancer. She had one treatment postponed due to counts. She had low blood counts this week requiring platelet transfusion, so we are going to dose reduce for six treatments by 10%. As far as the back pain, she clearly has evidence of progressive bone metastasis in T3, T11, T12, and T1 and questions about the soft tissue mass pleural base mass in the lateral left apex. I am going to refer back to Dr. X to see if there might be some palliative radiation to deal with the left back and scapular region.
1. Extensive stage small cell lung cancer.
2. Chemotherapy with carboplatin and etoposide.
3. Left scapular pain status post CT scan of the thorax.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with carboplatin and etoposide. She completed her fifth cycle on 08/12/10. She has had ongoing back pain and was sent for a CT scan of the thorax. She comes into clinic today accompanied by her daughters to review the results.
CURRENT MEDICATIONS: Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: The patient continues to have back pain some time she also take two pain pill. She received platelet transfusion the other day and reported mild fever. She denies any chills, night sweats, chest pain, or shortness of breath. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 118/60. HEART RATE: 76. TEMP: 97.8. Weight: 65.5 kg.
GEN: She looks well, in no acute distress.
HEENT: Her pupils were noted for surgical changes bilaterally. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds.
EXT: Lower extremities are without edema.
IMAGING: Her CT scan shows a pleural base mass in the left apex appears to have some growth along the medial margin comparing with PET/CT assessment 07/08/10. While this extends to the pleural surface it does not clearly invade directly into the chest wall or the adjacent posterior lateral left third rib. Left suprahilar and mediastinal adenopathy appears to be essentially stable since 07/08/10. Multilevel thoracic bony metastatic disease is present. Hypodense liver metastasis appears slightly improved comparing with July, more substantially improved comparing with chest CT of 04/21/10.
ASSESSMENT/PLAN: This is a very pleasant female 67-year-old female with extensive stage small cell lung cancer. She had one treatment postponed due to counts. She had low blood counts this week requiring platelet transfusion, so we are going to dose reduce for six treatments by 10%. As far as the back pain, she clearly has evidence of progressive bone metastasis in T3, T11, T12, and T1 and questions about the soft tissue mass pleural base mass in the lateral left apex. I am going to refer back to Dr. X to see if there might be some palliative radiation to deal with the left back and scapular region.
Sample Name:
Lymph Node Excisional Biopsy
Description: Left axillary lymph node excisional biopsy. Left axillary
adenopathy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Left axillary adenopathy.
POSTOPERATIVE DIAGNOSIS: Left axillary adenopathy.
PROCEDURE: Left axillary lymph node excisional biopsy.
ANESTHESIA: LMA.
INDICATIONS: Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.
TECHNIQUE: Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Left axillary adenopathy.
PROCEDURE: Left axillary lymph node excisional biopsy.
ANESTHESIA: LMA.
INDICATIONS: Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.
TECHNIQUE: Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.
Sample Name:
Lymphoblastic Leukemia - Consult
Description: Newly diagnosed high-risk acute lymphoblastic leukemia;
extensive deep vein thrombosis, and pharmacologic thrombolysis following
placement of a vena caval filter.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Newly diagnosed high-risk acute lymphoblastic leukemia;
extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC),
status post balloon angioplasty, and mechanical and pharmacologic thrombolysis
following placement of a vena caval filter.
HISTORY OF PRESENT ILLNESS: The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).
The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).
ALLERGIES: NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.
CURRENT MEDICATIONS:
1. Lovenox 60 mg subcutaneously q.12h. initiated.
2. Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.
3. Protonix 40 mg intravenous (IV) daily.
4. Vicodin p.r.n.
5. Levaquin 750 mg IV on 02/23/2007.
IMMUNIZATIONS: Up-to-date.
PAST SURGICAL HISTORY: The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.
FAMILY HISTORY: Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides.
SOCIAL HISTORY: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.
REVIEW OF SYSTEMS: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.
PHYSICAL EXAMINATION: GENERAL: Alert, cooperative, moderately ill-appearing young man.
VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.
HAIR AND SKIN: Mild facial acne.
HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.
CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).
LUNGS: Clear to auscultation with an occasional productive cough.
ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.
MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.
GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.
NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).
LABORATORY DATA: White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal.
ASSESSMENT: 1. Newly diagnosed high-risk acute lymphoblastic leukemia.
2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.
3. Probable chronic left epididymitis.
PLAN: 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.
2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.
3. Ultrasound/Doppler of the testicles.
4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.
HISTORY OF PRESENT ILLNESS: The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).
The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).
ALLERGIES: NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.
CURRENT MEDICATIONS:
1. Lovenox 60 mg subcutaneously q.12h. initiated.
2. Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.
3. Protonix 40 mg intravenous (IV) daily.
4. Vicodin p.r.n.
5. Levaquin 750 mg IV on 02/23/2007.
IMMUNIZATIONS: Up-to-date.
PAST SURGICAL HISTORY: The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.
FAMILY HISTORY: Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides.
SOCIAL HISTORY: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.
REVIEW OF SYSTEMS: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.
PHYSICAL EXAMINATION: GENERAL: Alert, cooperative, moderately ill-appearing young man.
VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.
HAIR AND SKIN: Mild facial acne.
HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.
CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).
LUNGS: Clear to auscultation with an occasional productive cough.
ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.
MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.
GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.
NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).
LABORATORY DATA: White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal.
ASSESSMENT: 1. Newly diagnosed high-risk acute lymphoblastic leukemia.
2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.
3. Probable chronic left epididymitis.
PLAN: 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.
2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.
3. Ultrasound/Doppler of the testicles.
4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.
Sample Name:
Lymphoma - Consult
Description: Marginal B-cell lymphoma, status post splenectomy.
Testicular swelling - possible epididymitis or possible torsion of the testis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient has a known case of marginal B-cell lymphoma
for which he underwent splenectomy two years ago. The patient, last year,
developed a diffuse large B-cell lymphoma which was treated with
CHOP/reduction. The patient again went into complete remission. The patient has
been doing well until recently, few days ago, late last week, when he developed
swelling of the left testicle. The patient states he has been having fever and
chills for the last few days. The patient felt weak and felt unwell. The
patient with these complaints came to the emergency room. The patient has been
having fever and chills and the patient states that the pain in the left
testicle is rather severe. No history of trauma to the testicle.
PAST MEDICAL HISTORY:
1. Status post splenectomy.
2. History of marginal B-cell lymphoma.
3. History of diffuse large cell lymphoma.
ALLERGIES: None.
PERSONAL HISTORY: Used to smoke and drink alcohol but at present does not.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
HEENT: Has slight headache.
CARDIOVASCULAR: No history of hypertension, MI, etc.
RESPIRATORY: No history of cough, asthma, TB, shortness of breath.
GI: Unremarkable.
GU: As above, has developed painful swelling of the left testicle over the last few days.
ENDOCRINE: Known case of type II diabetes mellitus.
PHYSICAL EXAMINATION:
HEENT: No conjunctival pallor or icterus.
NECK: No adenopathy. No carotid bruits.
LUNGS: Clear.
HEART: No gallop or murmur.
ABDOMEN: A midline scar is present.
EXTREMITIES: Unremarkable.
GENITALIA: Right testicle is markedly erythematous and swollen and tender.
LABORATORY DATA: WBC 13.8, hemoglobin 14.3, hematocrit 42.4, platelets 235,000. SMA-7 shows a potassium of 3.9. Glucose was 213 on September 18, 2007.
ASSESSMENT:
1. Left testicular swelling. It is tender. Etiology - possible epididymitis or possible torsion of the testis.
2. History of diffuse large cell lymphoma and remission.
3. History of marginal B-cell lymphoma, status post splenectomy two years ago.
4. History of diabetes mellitus.
PLAN:
1. Ultrasound of scrotum.
2. Urology consult.
3. Ultrasound of abdomen.
4. IV antibiotics.
5. We will arrange CT scan of the abdomen and pelvis in the future.
PAST MEDICAL HISTORY:
1. Status post splenectomy.
2. History of marginal B-cell lymphoma.
3. History of diffuse large cell lymphoma.
ALLERGIES: None.
PERSONAL HISTORY: Used to smoke and drink alcohol but at present does not.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
HEENT: Has slight headache.
CARDIOVASCULAR: No history of hypertension, MI, etc.
RESPIRATORY: No history of cough, asthma, TB, shortness of breath.
GI: Unremarkable.
GU: As above, has developed painful swelling of the left testicle over the last few days.
ENDOCRINE: Known case of type II diabetes mellitus.
PHYSICAL EXAMINATION:
HEENT: No conjunctival pallor or icterus.
NECK: No adenopathy. No carotid bruits.
LUNGS: Clear.
HEART: No gallop or murmur.
ABDOMEN: A midline scar is present.
EXTREMITIES: Unremarkable.
GENITALIA: Right testicle is markedly erythematous and swollen and tender.
LABORATORY DATA: WBC 13.8, hemoglobin 14.3, hematocrit 42.4, platelets 235,000. SMA-7 shows a potassium of 3.9. Glucose was 213 on September 18, 2007.
ASSESSMENT:
1. Left testicular swelling. It is tender. Etiology - possible epididymitis or possible torsion of the testis.
2. History of diffuse large cell lymphoma and remission.
3. History of marginal B-cell lymphoma, status post splenectomy two years ago.
4. History of diabetes mellitus.
PLAN:
1. Ultrasound of scrotum.
2. Urology consult.
3. Ultrasound of abdomen.
4. IV antibiotics.
5. We will arrange CT scan of the abdomen and pelvis in the future.
Sample Name:
Mantle Cell Lymphoma
Description: A 61-year-old white male with a diagnosis of mantle cell
lymphoma status post autologous transplant with BEAM regimen followed by
relapse. Allogeneic peripheral stem cell transplant from match-related brother
and the patient is 53 months out from transplant.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PRINCIPAL DIAGNOSES:
1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.
2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.
3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.
4. Diabetes.
5. Bipolar disorder.
6. Chronic muscle aches.
7. Chronic lower extremity edema.
8. ECOG performance status 1.
INTERIM HISTORY: The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.
He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.
CURRENT MEDICATIONS:
1. Paxil 40 mg once daily.
2. Cozaar.
3. Xanax 1 mg four times a day.
4. Prozac 20 mg a day.
5. Lasix 40 mg a day.
6. Potassium 10 mEq a day.
7. Mirapex two tablets every night.
8. Allegra 60 mg twice a day.
9. Avandamet 4/1000 mg daily.
10. Nexium 20 mg a day.
11. NovoLog 25/50.
REVIEW OF SYSTEMS: Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact.
LABORATORY DATA: White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31.
ASSESSMENT AND PLAN:
1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.
2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.
3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.
4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.
5. He is followed for his diabetes by his internist.
6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now.
1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.
2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.
3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.
4. Diabetes.
5. Bipolar disorder.
6. Chronic muscle aches.
7. Chronic lower extremity edema.
8. ECOG performance status 1.
INTERIM HISTORY: The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.
He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.
CURRENT MEDICATIONS:
1. Paxil 40 mg once daily.
2. Cozaar.
3. Xanax 1 mg four times a day.
4. Prozac 20 mg a day.
5. Lasix 40 mg a day.
6. Potassium 10 mEq a day.
7. Mirapex two tablets every night.
8. Allegra 60 mg twice a day.
9. Avandamet 4/1000 mg daily.
10. Nexium 20 mg a day.
11. NovoLog 25/50.
REVIEW OF SYSTEMS: Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact.
LABORATORY DATA: White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31.
ASSESSMENT AND PLAN:
1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.
2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.
3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.
4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.
5. He is followed for his diabetes by his internist.
6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now.
Sample Name:
Marginal Zone Lymphoma
Description: Marginal zone lymphoma (MALT-type lymphoma). A mass was found
in her right breast on physical examination. she had a mammogram and
ultrasound, which confirmed the right breast mass.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Marginal zone lymphoma.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).
Overall, she is doing well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. She has normal bowel and bladder habits. No melena or hematochezia.
CURRENT MEDICATIONS: Macrobid 100 mg q.d.
ALLERGIES: Sulfa, causes nausea and vomiting.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. She is status post a left partial nephrectomy as a new born.
2. In 2008 she had a right ankle fracture.
SOCIAL HISTORY: She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter.
FAMILY HISTORY: Her mother had uterine cancer. Her father had liver cancer.
PHYSICAL EXAM:
VIT: Height 165 cm, weight 105 kg, blood pressure 126/82, pulse is 62, and temperature is 98.2.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: MALT lymphoma. This time we need to check PET for staging purposes. I will also schedule her for a bone marrow biopsy and aspirate. The risks and benefits of an unsedated bone marrow biopsy and an aspirate were discussed with her and she consents to proceed without sedation. I am also going to schedule an EGD. I will also check a CBC, CMP and LDH. I will see her back when I have the results of her staging studies. We will then discuss further treatment at that time.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).
Overall, she is doing well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. She has normal bowel and bladder habits. No melena or hematochezia.
CURRENT MEDICATIONS: Macrobid 100 mg q.d.
ALLERGIES: Sulfa, causes nausea and vomiting.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. She is status post a left partial nephrectomy as a new born.
2. In 2008 she had a right ankle fracture.
SOCIAL HISTORY: She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter.
FAMILY HISTORY: Her mother had uterine cancer. Her father had liver cancer.
PHYSICAL EXAM:
VIT: Height 165 cm, weight 105 kg, blood pressure 126/82, pulse is 62, and temperature is 98.2.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: MALT lymphoma. This time we need to check PET for staging purposes. I will also schedule her for a bone marrow biopsy and aspirate. The risks and benefits of an unsedated bone marrow biopsy and an aspirate were discussed with her and she consents to proceed without sedation. I am also going to schedule an EGD. I will also check a CBC, CMP and LDH. I will see her back when I have the results of her staging studies. We will then discuss further treatment at that time.
Sample Name:
MediPort Placement
Description: Rhabdomyosarcoma of the left orbit. Left subclavian vein
MediPort placement. Needs chemotherapy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Rhabdomyosarcoma of the left orbit.
POSTOPERATIVE DIAGNOSIS: Rhabdomyosarcoma of the left orbit.
PROCEDURE: Left subclavian vein MediPort placement (7.5-French single-lumen).
INDICATIONS FOR PROCEDURE: This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit. The patient is being taken to the operating room for MediPort placement. She needs chemotherapy.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion. An incision was made on the left shoulder area. The left subclavian vein was cannulated. The wire was passed, which was in good position under fluoro, using Seldinger Technique. Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon. I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer. The line tip was in good position under fluoro. It withdrew and flushed well. I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips. Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush. We secured this with Tegaderm. The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.
POSTOPERATIVE DIAGNOSIS: Rhabdomyosarcoma of the left orbit.
PROCEDURE: Left subclavian vein MediPort placement (7.5-French single-lumen).
INDICATIONS FOR PROCEDURE: This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit. The patient is being taken to the operating room for MediPort placement. She needs chemotherapy.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion. An incision was made on the left shoulder area. The left subclavian vein was cannulated. The wire was passed, which was in good position under fluoro, using Seldinger Technique. Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon. I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer. The line tip was in good position under fluoro. It withdrew and flushed well. I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips. Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush. We secured this with Tegaderm. The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.
Sample Name:
Mesothelioma - Pleural Biopsy
Description: Right pleural effusion and suspected malignant mesothelioma.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right pleural effusion and suspected malignant mesothelioma.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion, suspected malignant mesothelioma.
PROCEDURE: Right VATS pleurodesis and pleural biopsy.
ANESTHESIA: General double-lumen endotracheal.
DESCRIPTION OF FINDINGS: Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.
SPECIMEN: Pleural biopsies for pathology and microbiology.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Crystalloid 1.2 L and 1.9 L of pleural effusion drained.
INDICATIONS: Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.
Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.
The counts were correct x2 at the end of the case.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion, suspected malignant mesothelioma.
PROCEDURE: Right VATS pleurodesis and pleural biopsy.
ANESTHESIA: General double-lumen endotracheal.
DESCRIPTION OF FINDINGS: Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.
SPECIMEN: Pleural biopsies for pathology and microbiology.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Crystalloid 1.2 L and 1.9 L of pleural effusion drained.
INDICATIONS: Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.
Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.
The counts were correct x2 at the end of the case.
Sample Name:
Mesothelioma - Port-A-Cath Insertion
Description: Biopsy-proven mesothelioma - Placement of Port-A-Cath, left
subclavian vein with fluoroscopy.
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(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Mesothelioma.
POSTOPERATIVE DIAGNOSIS: Mesothelioma.
OPERATIVE PROCEDURE: Placement of Port-A-Cath, left subclavian vein with fluoroscopy.
ASSISTANT: None.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma. He was brought to the operating room now for Port-A-Cath placement for chemotherapy. After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position. After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted. Needle was removed. Small incision was made large enough to harbor the port. Dilator and introducers were then placed over the guidewire. Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers. Introducers were peeled away without difficulty. He measured with fluoroscopy and cut to the appropriate length. The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium. It was then connected to the hub of the port. Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall. Wounds were then closed. Needle count, sponge count, and instrument counts were all correct.
POSTOPERATIVE DIAGNOSIS: Mesothelioma.
OPERATIVE PROCEDURE: Placement of Port-A-Cath, left subclavian vein with fluoroscopy.
ASSISTANT: None.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma. He was brought to the operating room now for Port-A-Cath placement for chemotherapy. After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position. After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted. Needle was removed. Small incision was made large enough to harbor the port. Dilator and introducers were then placed over the guidewire. Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers. Introducers were peeled away without difficulty. He measured with fluoroscopy and cut to the appropriate length. The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium. It was then connected to the hub of the port. Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall. Wounds were then closed. Needle count, sponge count, and instrument counts were all correct.
Sample Name:
Mesothelioma - Thoracotomy & Lobectomy
Description: Right nodular malignant mesothelioma.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right mesothelioma.
POSTOPERATIVE DIAGNOSIS: Right lung mass invading diaphragm and liver.
FINDINGS: Right lower lobe lung mass invading diaphragm and liver.
PROCEDURES:
1. Right thoracotomy.
2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.
SPECIMENS: Right lower lobectomy with en bloc resection of diaphragm and portion of liver.
BLOOD LOSS: 600 mL.
FLUIDS: Crystalloid 2.7 L and 1 unit packed red blood cells.
ANESTHESIA: Double-lumen endotracheal tube.
CONDITION: Stable, extubated, to PACU.
PROCEDURE IN DETAIL: Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm. He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma. Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm. He was explained the risks, benefits, and alternatives to this procedure. He wished to proceed, so he was brought to the operating room.
An epidural catheter was placed. He was put in a supine position where SCDs and Foley catheter were placed. He was put under general endotracheal anesthesia with a double-lumen endotracheal tube. He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.
A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered. Upon entering the chest, the chest wall retractor was inserted and the cavity inspected. It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm. He also had some marked lymphadenopathy. With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection. Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly. We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe. The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties. Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment. This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk. This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe. This was also ligated in continuity and actually doubly ligated. Care was taken to preserve the artery to the right and middle lobe.
We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein. The superior pulmonary vein was visualized as well. The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie. Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures. The bronchial anatomy was defined. Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe. A TA-30 4.8 stapler was then closed. The lung insufflated. The right middle lobe and right upper lobe were noted to inflate well. The stapler was fired, and the bronchus was cut with a 10-blade.
We then turned our attention to the diaphragm. There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin. Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved. It seemed that it would be a mucoid shallow portion. The Bovie was set to high cautery. The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver. It did leave quite a shallow defect in the liver. Hemostasis was achieved with Bovie cautery and gentle pressure. The specimen was then taken off the table and sent to Pathology for permanent. The area was inspected for hemostasis. A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension. A single 32 straight chest tube was also placed. The lung was seen to expand. We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe. Hemostasis was observed at the end of the case. The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump. The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs. The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin. The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.
Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.
POSTOPERATIVE DIAGNOSIS: Right lung mass invading diaphragm and liver.
FINDINGS: Right lower lobe lung mass invading diaphragm and liver.
PROCEDURES:
1. Right thoracotomy.
2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.
SPECIMENS: Right lower lobectomy with en bloc resection of diaphragm and portion of liver.
BLOOD LOSS: 600 mL.
FLUIDS: Crystalloid 2.7 L and 1 unit packed red blood cells.
ANESTHESIA: Double-lumen endotracheal tube.
CONDITION: Stable, extubated, to PACU.
PROCEDURE IN DETAIL: Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm. He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma. Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm. He was explained the risks, benefits, and alternatives to this procedure. He wished to proceed, so he was brought to the operating room.
An epidural catheter was placed. He was put in a supine position where SCDs and Foley catheter were placed. He was put under general endotracheal anesthesia with a double-lumen endotracheal tube. He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.
A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered. Upon entering the chest, the chest wall retractor was inserted and the cavity inspected. It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm. He also had some marked lymphadenopathy. With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection. Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly. We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe. The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties. Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment. This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk. This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe. This was also ligated in continuity and actually doubly ligated. Care was taken to preserve the artery to the right and middle lobe.
We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein. The superior pulmonary vein was visualized as well. The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie. Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures. The bronchial anatomy was defined. Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe. A TA-30 4.8 stapler was then closed. The lung insufflated. The right middle lobe and right upper lobe were noted to inflate well. The stapler was fired, and the bronchus was cut with a 10-blade.
We then turned our attention to the diaphragm. There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin. Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved. It seemed that it would be a mucoid shallow portion. The Bovie was set to high cautery. The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver. It did leave quite a shallow defect in the liver. Hemostasis was achieved with Bovie cautery and gentle pressure. The specimen was then taken off the table and sent to Pathology for permanent. The area was inspected for hemostasis. A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension. A single 32 straight chest tube was also placed. The lung was seen to expand. We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe. Hemostasis was observed at the end of the case. The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump. The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs. The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin. The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.
Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.
Sample Name:
Metastatic Ovarian Cancer - Consult
Description: A very pleasant 66-year-old woman with recurrent metastatic
ovarian cancer.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Metastatic ovarian cancer.
HISTORY OF PRESENT ILLNESS: Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic. She last saw Dr. X in clinic towards the beginning of this month. She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08. She was last seen in clinic on 12/22/08 by Dr. Y. At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000. Her ANC was 0.5. She was started on prophylactic Augmentin as well as Neupogen shots. She has also had history of recurrent pleural effusions with the knee for thoracentesis. She had two of these performed in November and the last one was done about a week ago.
Over the last 2 or 3 days, she states she has been getting more short of breath. Her history is somewhat limited today as she is very tired and falls asleep readily. Her history comes from herself but also from the review of the records. Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions. She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia. She specifically denied any fevers or chills. However, she was complaining of chest pain. She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough. When she did cough, it was nonproductive. While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations. An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes. The chest x-ray described above showed a right lower lobe infiltrate. A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe. The findings were compatible with an indeterminate study for a pulmonary embolism. Apparently, an ultrasound of the lower extremities was done and was negative for DVT. There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox. There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.
At this point, we have been consulted to help follow along with this patient who is well known to our clinic.
PAST MEDICAL HISTORY
1. Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO. This has recurred over the last couple of months with metastatic disease.
2. History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago. She has had no recurrent disease.
3. Renal cell carcinoma - She is status post nephrectomy.
4. Hypertension.
5. Anxiety disorder.
6. Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.
7. Ongoing tobacco use.
PAST SURGICAL HISTORY
1. Recent and multiple thoracentesis as described above.
2. Bilateral mastectomies.
3. Multiple abdominal surgeries.
4. Cholecystectomy.
5. Remote right ankle fracture.
ALLERGIES: No known drug allergies.
MEDICATIONS: At home,
1. Atenolol 50 mg daily
2. Ativan p.r.n.
3. Clonidine 0.1 mg nightly.
4. Compazine p.r.n.
5. Dilaudid p.r.n.
6. Gabapentin 300 mg p.o. t.i.d.
7. K-Dur 20 mEq p.o. daily.
8. Lasix unknown dose daily.
9. Norvasc 5 mg daily.
10. Zofran p.r.n.
SOCIAL HISTORY: She smokes about 6-7 cigarettes per day and has done so for more than 50 years. She quit smoking about 6 weeks ago. She occasionally has alcohol. She is married and has 3 children. She lives at home with her husband. She used to work as a unit clerk at XYZ Medical Center.
FAMILY HISTORY: Both her mother and father had a history of lung cancer and both were smokers.
REVIEW OF SYSTEMS: GENERAL/CONSTITUTIONAL: She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount. HEENT: She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears. CHEST: Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis. CVS: She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations. GI: No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools. GU: No dysuria, burning with urination, kidney stones, and difficulty voiding. MUSCULOSKELETAL: No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness. NEUROLOGIC: She has been diffusely weak but no lateralizing loss of strength or feeling. She has some chronic neuropathic pain and numbness as described above in the past medical history. She is fatigued and tired today and falls asleep while talking but is easily arousable. Some of this is related to her lack of sleep over the admission thus far.
PHYSICAL EXAMINATION
VITAL SIGNS: Her T-max is 99.3. Her pulse is 54, her respirations is 12, and blood pressure 118/61.
GENERAL: Somewhat fatigued appearing but in no acute distress.
HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without any erythema, exudate, or discharge.
NECK: Supple. Nontender. No elevated JVP. No thyromegaly. No thyroid nodules.
CHEST: Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.
CVS: Regular rate and rhythm. No murmurs, gallops or rubs. Normal S1 and S2. No S3 or S4.
ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds. No guarding or rebound. No hepatosplenomegaly. No masses.
MUSCULOSKELETAL: Generalized muscle weakness but no joint swelling or other abnormalities.
SKIN: No rashes, bruising, or petechia. No non-healing wounds or ulcerations.
NEUROLOGIC: She is oriented x3 but she falls asleep readily. On exam and conversation, her cranial nerves are intact. She has no sensory loss. Her strength is symmetric.
LABORATORY DATA: Her white blood cell count is 8.0, hemoglobin 11.1, hematocrit 33.2%, and platelets 29,000. Her differential shows 2% metamyelocytes, 57% neutrophils, 29% bands, 6% lymphocytes, 5% monocytes, and 1% eosinophils. Her sodium is 138, potassium 4.0, chloride 101, CO2 of 23, BUN 21, creatinine 1.4, glucose 107, and calcium 8.7. Her INR is 1.0, PT of 12, and PTT 24. Urinalysis negative for nitrite and leukocyte esterase with moderate epithelial cells, bacteria, white blood cells, and yeast suggesting of contamination. Her troponins have been negative x3.
IMAGINING DATA: CT scan of her chest on 12/25/08 shows bilateral pleural effusions, larger on the right than the left but these are somewhat decreased in size compared to the prior CT scan at the end of November. There is some consolidative atelectasis at the bilateral basis. There is some peripheral interstitial opacifications noted in the right lung and to a lesser extent in the left lung possibly consistent with pneumonitis. There are small peripheral nodular densities in both lungs unchanged compared to prior scan. There is an enlarged right adrenal gland again noted without change.
ASSESSMENT: ABCD is a very pleasant 66-year-old woman with recurrent metastatic ovarian cancer known to our clinic. At this point, she has been admitted for shortness of breath with possible presumed pneumonia. The possibility of a PE also remains and the plan has been to do a CTA once her kidney function improves. Currently, she is being treated with broad-spectrum antibiotics and Lovenox prophylactically.
At this point, it does not appear that her pleural effusions have increased and this would not be the etiology behind her worsening symptoms. Her blood counts appear to be recovering from chemotherapy except for the fact that her platelets have gone lower. It is unclear as to the etiology behind this but may still be related to chemotherapy effect. This also could be related to consumptive process such as DIC in the face of infections or medication effect. We will keep track of her blood counts over this admission.
We will continue to follow along through the course of her admission. She has requested being full code. I went back and looked at Dr. X's chart after our clinic chart and at the last visit with Dr. X and Dr. Y, she confirmed that she wanted to be DNR/DNI. I am not sure why this is changed and I will address this issue with her once she is more alert.
Thank you very much for this consult.
HISTORY OF PRESENT ILLNESS: Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic. She last saw Dr. X in clinic towards the beginning of this month. She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08. She was last seen in clinic on 12/22/08 by Dr. Y. At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000. Her ANC was 0.5. She was started on prophylactic Augmentin as well as Neupogen shots. She has also had history of recurrent pleural effusions with the knee for thoracentesis. She had two of these performed in November and the last one was done about a week ago.
Over the last 2 or 3 days, she states she has been getting more short of breath. Her history is somewhat limited today as she is very tired and falls asleep readily. Her history comes from herself but also from the review of the records. Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions. She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia. She specifically denied any fevers or chills. However, she was complaining of chest pain. She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough. When she did cough, it was nonproductive. While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations. An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes. The chest x-ray described above showed a right lower lobe infiltrate. A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe. The findings were compatible with an indeterminate study for a pulmonary embolism. Apparently, an ultrasound of the lower extremities was done and was negative for DVT. There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox. There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.
At this point, we have been consulted to help follow along with this patient who is well known to our clinic.
PAST MEDICAL HISTORY
1. Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO. This has recurred over the last couple of months with metastatic disease.
2. History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago. She has had no recurrent disease.
3. Renal cell carcinoma - She is status post nephrectomy.
4. Hypertension.
5. Anxiety disorder.
6. Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.
7. Ongoing tobacco use.
PAST SURGICAL HISTORY
1. Recent and multiple thoracentesis as described above.
2. Bilateral mastectomies.
3. Multiple abdominal surgeries.
4. Cholecystectomy.
5. Remote right ankle fracture.
ALLERGIES: No known drug allergies.
MEDICATIONS: At home,
1. Atenolol 50 mg daily
2. Ativan p.r.n.
3. Clonidine 0.1 mg nightly.
4. Compazine p.r.n.
5. Dilaudid p.r.n.
6. Gabapentin 300 mg p.o. t.i.d.
7. K-Dur 20 mEq p.o. daily.
8. Lasix unknown dose daily.
9. Norvasc 5 mg daily.
10. Zofran p.r.n.
SOCIAL HISTORY: She smokes about 6-7 cigarettes per day and has done so for more than 50 years. She quit smoking about 6 weeks ago. She occasionally has alcohol. She is married and has 3 children. She lives at home with her husband. She used to work as a unit clerk at XYZ Medical Center.
FAMILY HISTORY: Both her mother and father had a history of lung cancer and both were smokers.
REVIEW OF SYSTEMS: GENERAL/CONSTITUTIONAL: She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount. HEENT: She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears. CHEST: Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis. CVS: She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations. GI: No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools. GU: No dysuria, burning with urination, kidney stones, and difficulty voiding. MUSCULOSKELETAL: No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness. NEUROLOGIC: She has been diffusely weak but no lateralizing loss of strength or feeling. She has some chronic neuropathic pain and numbness as described above in the past medical history. She is fatigued and tired today and falls asleep while talking but is easily arousable. Some of this is related to her lack of sleep over the admission thus far.
PHYSICAL EXAMINATION
VITAL SIGNS: Her T-max is 99.3. Her pulse is 54, her respirations is 12, and blood pressure 118/61.
GENERAL: Somewhat fatigued appearing but in no acute distress.
HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without any erythema, exudate, or discharge.
NECK: Supple. Nontender. No elevated JVP. No thyromegaly. No thyroid nodules.
CHEST: Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.
CVS: Regular rate and rhythm. No murmurs, gallops or rubs. Normal S1 and S2. No S3 or S4.
ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds. No guarding or rebound. No hepatosplenomegaly. No masses.
MUSCULOSKELETAL: Generalized muscle weakness but no joint swelling or other abnormalities.
SKIN: No rashes, bruising, or petechia. No non-healing wounds or ulcerations.
NEUROLOGIC: She is oriented x3 but she falls asleep readily. On exam and conversation, her cranial nerves are intact. She has no sensory loss. Her strength is symmetric.
LABORATORY DATA: Her white blood cell count is 8.0, hemoglobin 11.1, hematocrit 33.2%, and platelets 29,000. Her differential shows 2% metamyelocytes, 57% neutrophils, 29% bands, 6% lymphocytes, 5% monocytes, and 1% eosinophils. Her sodium is 138, potassium 4.0, chloride 101, CO2 of 23, BUN 21, creatinine 1.4, glucose 107, and calcium 8.7. Her INR is 1.0, PT of 12, and PTT 24. Urinalysis negative for nitrite and leukocyte esterase with moderate epithelial cells, bacteria, white blood cells, and yeast suggesting of contamination. Her troponins have been negative x3.
IMAGINING DATA: CT scan of her chest on 12/25/08 shows bilateral pleural effusions, larger on the right than the left but these are somewhat decreased in size compared to the prior CT scan at the end of November. There is some consolidative atelectasis at the bilateral basis. There is some peripheral interstitial opacifications noted in the right lung and to a lesser extent in the left lung possibly consistent with pneumonitis. There are small peripheral nodular densities in both lungs unchanged compared to prior scan. There is an enlarged right adrenal gland again noted without change.
ASSESSMENT: ABCD is a very pleasant 66-year-old woman with recurrent metastatic ovarian cancer known to our clinic. At this point, she has been admitted for shortness of breath with possible presumed pneumonia. The possibility of a PE also remains and the plan has been to do a CTA once her kidney function improves. Currently, she is being treated with broad-spectrum antibiotics and Lovenox prophylactically.
At this point, it does not appear that her pleural effusions have increased and this would not be the etiology behind her worsening symptoms. Her blood counts appear to be recovering from chemotherapy except for the fact that her platelets have gone lower. It is unclear as to the etiology behind this but may still be related to chemotherapy effect. This also could be related to consumptive process such as DIC in the face of infections or medication effect. We will keep track of her blood counts over this admission.
We will continue to follow along through the course of her admission. She has requested being full code. I went back and looked at Dr. X's chart after our clinic chart and at the last visit with Dr. X and Dr. Y, she confirmed that she wanted to be DNR/DNI. I am not sure why this is changed and I will address this issue with her once she is more alert.
Thank you very much for this consult.
Sample Name:
MGUS Followup
Description: MGUS. His bone marrow biopsy showed a normal cellular bone
marrow; however, there were 10% plasma cells and we proceeded with the workup
for a plasma cell dyscrasia. All his tests came back as consistent with an
MGUS.
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CHIEF COMPLAINT: MGUS.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS.
Overall, he is doing well. Since I last saw him, he tells me that he has had onset of atrial fibrillation. He has now started going to the gym two times per week, and has lost over 10 pounds. He has a good energy level and his ECOG performance status is 0. He denies any fever, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax 0.4 mg q.d., and Warfarin 2.5 mg q.d.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. He is status post left inguinal hernia repair.
2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron.
SOCIAL HISTORY: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married.
FAMILY HISTORY: His brother had prostate cancer.
PHYSICAL EXAM:
VIT: Height 175 cm, weight 77 kg, blood pressure 138/76, pulse is 58, and temperature is 97.0.
GEN: He is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: MGUS. His serum protein electrophoresis showed that his M-spike overall is stable at 0.5. He is doing well and I will see him again with repeat laboratory studies in six months.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS.
Overall, he is doing well. Since I last saw him, he tells me that he has had onset of atrial fibrillation. He has now started going to the gym two times per week, and has lost over 10 pounds. He has a good energy level and his ECOG performance status is 0. He denies any fever, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax 0.4 mg q.d., and Warfarin 2.5 mg q.d.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. He is status post left inguinal hernia repair.
2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron.
SOCIAL HISTORY: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married.
FAMILY HISTORY: His brother had prostate cancer.
PHYSICAL EXAM:
VIT: Height 175 cm, weight 77 kg, blood pressure 138/76, pulse is 58, and temperature is 97.0.
GEN: He is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: MGUS. His serum protein electrophoresis showed that his M-spike overall is stable at 0.5. He is doing well and I will see him again with repeat laboratory studies in six months.
Sample Name:
Mullerian Adenosarcoma
Description: Discharge summary of a patient presenting with a large mass
aborted through the cervix.
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PRINCIPAL DIAGNOSIS: Mullerian adenosarcoma.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old presenting with a large mass aborted through the cervix.
PHYSICAL EXAM:
CHEST: Clear. There is no heart murmur.
ABDOMEN: Nontender.
PELVIC: There is a large mass in the vagina.
HOSPITAL COURSE: The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day.
OPERATIONS: July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy.
DISCHARGE CONDITION: Stable.
PLAN: The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week.
PATHOLOGY: Mullerian adenosarcoma.
MEDICATIONS: Percocet 5, #40, one q.3 h. p.r.n. pain.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old presenting with a large mass aborted through the cervix.
PHYSICAL EXAM:
CHEST: Clear. There is no heart murmur.
ABDOMEN: Nontender.
PELVIC: There is a large mass in the vagina.
HOSPITAL COURSE: The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day.
OPERATIONS: July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy.
DISCHARGE CONDITION: Stable.
PLAN: The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week.
PATHOLOGY: Mullerian adenosarcoma.
MEDICATIONS: Percocet 5, #40, one q.3 h. p.r.n. pain.
Sample Name:
Neck Dissection
Description: Left neck dissection. Metastatic papillary cancer, left
neck. The patient had thyroid cancer, papillary cell type, removed with a total
thyroidectomy and then subsequently recurrent disease was removed with a
paratracheal dissection.
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PREOPERATIVE DIAGNOSIS: Metastatic papillary cancer, left neck.
POSTOPERATIVE DIAGNOSIS: Metastatic papillary cancer, left neck.
OPERATION PERFORMED: Left neck dissection.
ANESTHESIA: General endotracheal.
INDICATIONS: The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection. He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer. Left neck dissection is indicated.
DESCRIPTION OF OPERATION: The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the table was then turned. A shoulder roll placed under the shoulders and the face was placed in an extended fashion. The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion. A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode. Subplatysmal superior and inferior flaps were raised. The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4. The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck. This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region. The submandibular gland was removed as well. The X, XI, and XII cranial nerves were preserved. The internal jugular vein and carotid artery were preserved as well. Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure. There were two obviously positive nodes in this neck dissection. One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2. A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature. The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples. A fluff and Kling pressure dressing was then applied. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.
POSTOPERATIVE DIAGNOSIS: Metastatic papillary cancer, left neck.
OPERATION PERFORMED: Left neck dissection.
ANESTHESIA: General endotracheal.
INDICATIONS: The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection. He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer. Left neck dissection is indicated.
DESCRIPTION OF OPERATION: The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the table was then turned. A shoulder roll placed under the shoulders and the face was placed in an extended fashion. The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion. A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode. Subplatysmal superior and inferior flaps were raised. The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4. The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck. This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region. The submandibular gland was removed as well. The X, XI, and XII cranial nerves were preserved. The internal jugular vein and carotid artery were preserved as well. Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure. There were two obviously positive nodes in this neck dissection. One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2. A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature. The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples. A fluff and Kling pressure dressing was then applied. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.
Sample Name:
Neck Mass Biopsy
Description: Malignant mass of the left neck, squamous cell carcinoma.
Left neck mass biopsy and selective surgical neck dissection, left.
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PREOPERATIVE DIAGNOSIS: Malignant mass of the left neck.
POSTOPERATIVE DIAGNOSIS: Malignant mass of the left neck, squamous cell carcinoma.
PROCEDURES
1. Left neck mass biopsy.
2. Selective surgical neck dissection, left.
DESCRIPTION OF PROCEDURE: After obtaining an informed, the patient was taken to the operating room where a time-out process was followed. Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room. Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.
Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation. The neck was prepped and draped in the usual fashion. I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap. Then, I performed an extensive anesthetic block of the area.
Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass. The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck. A wedge sample was sent to Pathology for frozen section. At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen. Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements. This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface. There, there were some attachments to branches of the external carotid artery, which had to be suture ligated. At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.
With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck. This worked out quite nicely. The external jugular vein was out of the way, so initially we did not deal with it. We proceeded to tackle the area III and extended into II-A. When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise. Also, I felt that the submaxillary gland was enlarged. At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.
The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle. At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination. Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen. Hemostasis was revised and found to be adequate. The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap. The flap was replaced in its position. A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin. I would like to mention that also the facial vein was excised and the external jugular vein was ligated. It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it. A pressure dressing was applied.
The patient tolerated the procedure well. Estimated blood loss was no more than 100 mL. The patient was extubated in the operating room and sent for recovery.
POSTOPERATIVE DIAGNOSIS: Malignant mass of the left neck, squamous cell carcinoma.
PROCEDURES
1. Left neck mass biopsy.
2. Selective surgical neck dissection, left.
DESCRIPTION OF PROCEDURE: After obtaining an informed, the patient was taken to the operating room where a time-out process was followed. Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room. Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.
Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation. The neck was prepped and draped in the usual fashion. I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap. Then, I performed an extensive anesthetic block of the area.
Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass. The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck. A wedge sample was sent to Pathology for frozen section. At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen. Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements. This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface. There, there were some attachments to branches of the external carotid artery, which had to be suture ligated. At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.
With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck. This worked out quite nicely. The external jugular vein was out of the way, so initially we did not deal with it. We proceeded to tackle the area III and extended into II-A. When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise. Also, I felt that the submaxillary gland was enlarged. At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.
The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle. At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination. Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen. Hemostasis was revised and found to be adequate. The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap. The flap was replaced in its position. A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin. I would like to mention that also the facial vein was excised and the external jugular vein was ligated. It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it. A pressure dressing was applied.
The patient tolerated the procedure well. Estimated blood loss was no more than 100 mL. The patient was extubated in the operating room and sent for recovery.
Sample Name:
Needle Localized Excision - Breast Neoplasm
Description: Nonpalpable neoplasm, right breast. Needle localized wide
excision of nonpalpable neoplasm, right breast.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Nonpalpable neoplasm, right breast.
POSTOPERATIVE DIAGNOSIS: Deferred for Pathology.
PROCEDURE PERFORMED: Needle localized wide excision of nonpalpable neoplasm, right breast.
SPECIMEN: Mammography.
GROSS FINDINGS: This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.
OPERATIVE PROCEDURE: The patient was taken to the operating room, placed in supine position in the operating table. Intravenous sedation was administered by the Anesthesia Department. The Kopans wire was trimmed to an appropriate length. The patient was sterilely prepped and draped in the usual manner. Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision. A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire. The wire was stabilized and brought to protrude through the incision. Skin flaps were then generated with electrocautery. A generous core tissue was grasped with Allis forceps and excised with electrocautery. Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short. The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along. The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.
The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well.
POSTOPERATIVE DIAGNOSIS: Deferred for Pathology.
PROCEDURE PERFORMED: Needle localized wide excision of nonpalpable neoplasm, right breast.
SPECIMEN: Mammography.
GROSS FINDINGS: This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.
OPERATIVE PROCEDURE: The patient was taken to the operating room, placed in supine position in the operating table. Intravenous sedation was administered by the Anesthesia Department. The Kopans wire was trimmed to an appropriate length. The patient was sterilely prepped and draped in the usual manner. Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision. A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire. The wire was stabilized and brought to protrude through the incision. Skin flaps were then generated with electrocautery. A generous core tissue was grasped with Allis forceps and excised with electrocautery. Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short. The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along. The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.
The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well.
Sample Name:
Neuroblastoma - Consult
Description: The patient is an 11-month-old with a diagnosis of stage 2
neuroblastoma of the right adrenal gland with favorable Shimada histology and
history of stage 2 left adrenal neuroblastoma, status post gross total
resection.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR VISIT: The patient is an 11-month-old with a diagnosis of stage 2
neuroblastoma here for ongoing management of his disease and the visit is
supervised by Dr. X.
HISTORY OF PRESENT ILLNESS: The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.
REVIEW OF SYSTEMS: The following systems reviewed and negative per pathology except as noted above. Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic.
PAST MEDICAL HISTORY: Reviewed as above and otherwise unchanged.
FAMILY HISTORY: Reviewed and unchanged.
SOCIAL HISTORY: The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.
MEDICATIONS:
1. Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.
2. G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.
3. Fluconazole 37.5 mg daily.
4. Zofran 1.5 mg every 6 hours as needed for nausea.
ALLERGIES: No known drug allergies.
FINDINGS: A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. Vital Signs: Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg. Eyes: Conjunctivae are clear, nonicteric. Pupils are equally round and reactive to light. Extraocular muscle movements appear intact with no strabismus. Ears: TMs are clear bilaterally. Oral Mucosa: No thrush is appreciated. No mucosal ulcerations or erythema. Chest: Port-a-Cath is nonerythematous and nontender to VP access port. Respiratory: Good aeration, clear to auscultation bilaterally. Cardiovascular: Regular rate, normal S1 and S2, no murmurs appreciated. Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. Skin: No rashes. Neurologic: The patient walks without assistance, frequently falls on his bottom.
LABORATORY STUDIES: CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974. Medical tests none. Radiologic studies are none.
ASSESSMENT: This patient's disease is life threatening, currently causing moderately severe side effects.
PROBLEMS DIAGNOSES:
1. Neuroblastoma of the right adrenal gland with favorable Shimada histology.
2. History of stage 2 left adrenal neuroblastoma, status post gross total resection.
3. Immunosuppression.
4. Mucosal candidiasis.
5. Resolving neutropenia.
PROCEDURES AND IMMUNIZATIONS: None.
PLANS:
1. Neuroblastoma. The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. I will plan for restaging with CT of the abdomen prior to the cycle.
2. Immunosuppression. The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday. Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.
3. Mucosal candidiasis. We will continue fluconazole for thrush. I am pleased that the clinical evidence of disease appears to have resolved. For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time. We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.
PEDIATRIC ONCOLOGY ATTENDING: I have reviewed the history of the patient. This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF. His ANC is nicely recovered. He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. He continues on fluconazole for recent history of thrush. Plans are otherwise documented above.
HISTORY OF PRESENT ILLNESS: The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.
REVIEW OF SYSTEMS: The following systems reviewed and negative per pathology except as noted above. Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic.
PAST MEDICAL HISTORY: Reviewed as above and otherwise unchanged.
FAMILY HISTORY: Reviewed and unchanged.
SOCIAL HISTORY: The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.
MEDICATIONS:
1. Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.
2. G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.
3. Fluconazole 37.5 mg daily.
4. Zofran 1.5 mg every 6 hours as needed for nausea.
ALLERGIES: No known drug allergies.
FINDINGS: A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. Vital Signs: Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg. Eyes: Conjunctivae are clear, nonicteric. Pupils are equally round and reactive to light. Extraocular muscle movements appear intact with no strabismus. Ears: TMs are clear bilaterally. Oral Mucosa: No thrush is appreciated. No mucosal ulcerations or erythema. Chest: Port-a-Cath is nonerythematous and nontender to VP access port. Respiratory: Good aeration, clear to auscultation bilaterally. Cardiovascular: Regular rate, normal S1 and S2, no murmurs appreciated. Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. Skin: No rashes. Neurologic: The patient walks without assistance, frequently falls on his bottom.
LABORATORY STUDIES: CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974. Medical tests none. Radiologic studies are none.
ASSESSMENT: This patient's disease is life threatening, currently causing moderately severe side effects.
PROBLEMS DIAGNOSES:
1. Neuroblastoma of the right adrenal gland with favorable Shimada histology.
2. History of stage 2 left adrenal neuroblastoma, status post gross total resection.
3. Immunosuppression.
4. Mucosal candidiasis.
5. Resolving neutropenia.
PROCEDURES AND IMMUNIZATIONS: None.
PLANS:
1. Neuroblastoma. The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. I will plan for restaging with CT of the abdomen prior to the cycle.
2. Immunosuppression. The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday. Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.
3. Mucosal candidiasis. We will continue fluconazole for thrush. I am pleased that the clinical evidence of disease appears to have resolved. For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time. We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.
PEDIATRIC ONCOLOGY ATTENDING: I have reviewed the history of the patient. This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF. His ANC is nicely recovered. He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. He continues on fluconazole for recent history of thrush. Plans are otherwise documented above.
Sample Name:
Non-Hodgkin lymphoma Followup
Description: Follicular non-Hodgkin's lymphoma. Biopsy of a left
posterior auricular lymph node and pathology showed follicular non-Hodgkin's
lymphoma. Received six cycles of CHOP chemotherapy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Follicular non-Hodgkin's lymphoma.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.
Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.
2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation.
3. History of congestive heart failure.
4. History of schwannoma resection. It was resected from T12 to L1 in 1991.
5. He has chronic obstruction of his inferior vena cava.
6. Recurrent lower extremity cellulitis.
SOCIAL HISTORY: He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister.
FAMILY HISTORY: His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family.
PHYSICAL EXAM:
VIT: Height 168 cm, weight 90.5 kg, blood pressure 106/58, pulse 68, and temperature is 97.3.
GEN: He is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Follicular non-Hodgkin's lymphoma. His CBC and CMP are acceptable and LDH is 121. Overall, he is doing well. When I see him again in three months, I will repeat his laboratory studies as well his PET scan.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.
Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.
2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation.
3. History of congestive heart failure.
4. History of schwannoma resection. It was resected from T12 to L1 in 1991.
5. He has chronic obstruction of his inferior vena cava.
6. Recurrent lower extremity cellulitis.
SOCIAL HISTORY: He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister.
FAMILY HISTORY: His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family.
PHYSICAL EXAM:
VIT: Height 168 cm, weight 90.5 kg, blood pressure 106/58, pulse 68, and temperature is 97.3.
GEN: He is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Follicular non-Hodgkin's lymphoma. His CBC and CMP are acceptable and LDH is 121. Overall, he is doing well. When I see him again in three months, I will repeat his laboratory studies as well his PET scan.
Sample Name:
Non-Small Cell Lung Cancer - Consult
Description: New diagnosis of non-small cell lung cancer stage IV
metastatic disease. At this point, he and his wife ask about whether this is
curable disease and it was difficult to inform that this was not curable
disease but would be treatable.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: New diagnosis of non-small cell lung cancer.
HISTORY OF PRESENT ILLNESS: ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease. We are consulted at this time to discuss further treatment options.
ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain. Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened. Eventually this prompted him to present to the emergency room. A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease. At that point, he was transferred to XYZ Hospital for further evaluation. On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes. The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum. This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery. There was an abnormal lymph node noted in the AP window and left hilar region. There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm. There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease. There were areas of atelectasis particularly in the right base. There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing. There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax. In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor. All other structures appeared normal. On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed. Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma. At this point, we have been consulted to discuss further treatment options.
On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite. He has not ever had a chronic smoker's cough and still does not have a cough. He has no sputum production or hemoptysis. He and his wife are very anxious about this diagnosis.
PAST MEDICAL HISTORY: He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.
PAST SURGICAL HISTORY: He denies having any surgeries.
ALLERGIES: No known drug allergies.
MEDICATIONS: At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain. He does take a multivitamin on occasion.
SOCIAL HISTORY: He has about a 30-pack-a-year history of smoking. He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked. Since that time he has worked with printing press. He is married and has two children, both of whom are grown in their 20s, but are now living at home.
FAMILY HISTORY: His mother died for alcohol-related complications. He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.
REVIEW OF SYSTEMS: GENERAL/CONSTITUTIONAL: He has lost about 20 pounds of weight as described above. He also has a trouble with fatigue. No lightheadedness or dizziness. HEENT: He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year. He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain. RESPIRATORY: He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest. No cough, congestion, wheezing, hemoptysis, and sputum production. CVS: He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities. GI: He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools. He has been somewhat constipated recently. GU: He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems. MUSCULOSKELETAL: He denies any new bony aches or pains including back pain, hip pain, and rib pain. No muscle aches, no joint swelling, and no history of gout. SKIN: No rashes, no bruising, petechia, non-healing wounds, or ulcerations. He has had no nail or hair changes. HEM: He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps. ENDOCRINE: He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors. NEURO: He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.
PHYSICAL EXAMINATION
VITAL SIGNS: His T-max is 98.8. His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.
GENERAL: No acute distress, pleasant gentleman who appears stated age.
HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without erythema, exudate, or discharge.
NECK: Supple. Nontender. No elevated JVP. No carotid bruits. No thyromegaly. No thyroid nodules. Carotids are 2+ and symmetric.
BACK: Spine is straight. No spinal tenderness. No CVA tenderness. No presacral edema.
CHEST: Clear to auscultation and percussion bilaterally. No wheezes, rales, or rhonchi. Normal symmetric chest wall expansion with inspiration.
CVS: Regular rate and rhythm. No murmurs, gallops, or rubs.
ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly. No guarding or rebound. No masses. Normoactive bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema. No joint swelling. Full range of motion.
SKIN: No rashes, wounds, ulcerations, bruises, or petechia.
NEUROLOGIC: Cranial nerves II through XII are intact. He has intact sensation to light touch throughout. He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes. He is alert and oriented x3.
LABORATORY DATA: His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000. The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils. Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7. His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.
IMAGINING DATA: MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter. There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.
ASSESSMENT/PLAN: ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable. His wife particularly had a very hard time with this prognosis. They preferred not to know the exact average as to how long someone lives with this disease. I did offer chemotherapy as a way to treat this disease. Chemotherapy has been associated both with palliation of symptoms as well as prolong survival. At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.
In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal. I would likely use carboplatin and gemcitabine. This would be both medications given on day 1 with a dose of gemcitabine on day 8. This cycle will be repeated after 1-week break so that the cycle lasts 21 days. The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.
In terms of staging Mr. ABCD'S had all the appropriate staging. A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.
At this point, his biggest issue is pain and he is getting a pain consult to help control his pain. He will be ready to be discharged from the hospital once his pain is under better control. As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday. At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.
Thank you very much for this interesting consult.
HISTORY OF PRESENT ILLNESS: ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease. We are consulted at this time to discuss further treatment options.
ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain. Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened. Eventually this prompted him to present to the emergency room. A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease. At that point, he was transferred to XYZ Hospital for further evaluation. On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes. The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum. This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery. There was an abnormal lymph node noted in the AP window and left hilar region. There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm. There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease. There were areas of atelectasis particularly in the right base. There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing. There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax. In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor. All other structures appeared normal. On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed. Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma. At this point, we have been consulted to discuss further treatment options.
On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite. He has not ever had a chronic smoker's cough and still does not have a cough. He has no sputum production or hemoptysis. He and his wife are very anxious about this diagnosis.
PAST MEDICAL HISTORY: He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.
PAST SURGICAL HISTORY: He denies having any surgeries.
ALLERGIES: No known drug allergies.
MEDICATIONS: At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain. He does take a multivitamin on occasion.
SOCIAL HISTORY: He has about a 30-pack-a-year history of smoking. He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked. Since that time he has worked with printing press. He is married and has two children, both of whom are grown in their 20s, but are now living at home.
FAMILY HISTORY: His mother died for alcohol-related complications. He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.
REVIEW OF SYSTEMS: GENERAL/CONSTITUTIONAL: He has lost about 20 pounds of weight as described above. He also has a trouble with fatigue. No lightheadedness or dizziness. HEENT: He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year. He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain. RESPIRATORY: He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest. No cough, congestion, wheezing, hemoptysis, and sputum production. CVS: He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities. GI: He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools. He has been somewhat constipated recently. GU: He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems. MUSCULOSKELETAL: He denies any new bony aches or pains including back pain, hip pain, and rib pain. No muscle aches, no joint swelling, and no history of gout. SKIN: No rashes, no bruising, petechia, non-healing wounds, or ulcerations. He has had no nail or hair changes. HEM: He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps. ENDOCRINE: He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors. NEURO: He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.
PHYSICAL EXAMINATION
VITAL SIGNS: His T-max is 98.8. His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.
GENERAL: No acute distress, pleasant gentleman who appears stated age.
HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without erythema, exudate, or discharge.
NECK: Supple. Nontender. No elevated JVP. No carotid bruits. No thyromegaly. No thyroid nodules. Carotids are 2+ and symmetric.
BACK: Spine is straight. No spinal tenderness. No CVA tenderness. No presacral edema.
CHEST: Clear to auscultation and percussion bilaterally. No wheezes, rales, or rhonchi. Normal symmetric chest wall expansion with inspiration.
CVS: Regular rate and rhythm. No murmurs, gallops, or rubs.
ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly. No guarding or rebound. No masses. Normoactive bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema. No joint swelling. Full range of motion.
SKIN: No rashes, wounds, ulcerations, bruises, or petechia.
NEUROLOGIC: Cranial nerves II through XII are intact. He has intact sensation to light touch throughout. He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes. He is alert and oriented x3.
LABORATORY DATA: His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000. The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils. Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7. His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.
IMAGINING DATA: MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter. There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.
ASSESSMENT/PLAN: ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable. His wife particularly had a very hard time with this prognosis. They preferred not to know the exact average as to how long someone lives with this disease. I did offer chemotherapy as a way to treat this disease. Chemotherapy has been associated both with palliation of symptoms as well as prolong survival. At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.
In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal. I would likely use carboplatin and gemcitabine. This would be both medications given on day 1 with a dose of gemcitabine on day 8. This cycle will be repeated after 1-week break so that the cycle lasts 21 days. The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.
In terms of staging Mr. ABCD'S had all the appropriate staging. A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.
At this point, his biggest issue is pain and he is getting a pain consult to help control his pain. He will be ready to be discharged from the hospital once his pain is under better control. As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday. At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.
Thank you very much for this interesting consult.
Sample Name:
Nuclear Medicine Lymphatic Scan
Description: Left breast cancer. Nuclear medicine lymphatic scan. A
16-hour left anterior oblique imaging was performed with and without shielding
of the original injection site.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
EXAM: Nuclear medicine lymphatic scan.
REASON FOR EXAM: Left breast cancer.
TECHNIQUE: 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.
FINDINGS: There are two small foci of increased activity in the left axilla. This is consistent with the sentinel lymph node. No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.
IMPRESSION: Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.
REASON FOR EXAM: Left breast cancer.
TECHNIQUE: 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.
FINDINGS: There are two small foci of increased activity in the left axilla. This is consistent with the sentinel lymph node. No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.
IMPRESSION: Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.
Sample Name:
Parathyroid Adenoma Excision
Description: Excision of right superior parathyroid adenoma, seen on sestamibi
parathyroid scan and an ultrasound.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right superior parathyroid adenoma.
POSTOPERATIVE DIAGNOSIS: Right superior parathyroid adenoma.
PROCEDURE: Excision of right superior parathyroid adenoma.
ANESTHESIA: Local with 1% Xylocaine and anesthesia standby with sedation.
CLINICAL HISTORY: This 80-year-old woman has had some mild dementia. She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations. She was found to be hypercalcemic. Intact PTH was mildly elevated. A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.
FINDINGS AND PROCEDURE: The patient was placed on the operating table in the supine position. A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan. The electronic medical record was reviewed as was the ultrasound. The patient was sedated. A small roll was placed behind the shoulders to moderately hyperextend the neck. The head was supported in a foam head cradle. The neck and chest were prepped with chlorhexidine and isolated with sterile drapes. After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma. The larger anterior neck veins were divided between 4-0 silk ligatures. Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection. The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally. The right sternothyroid muscle was divided transversely with the cautery. The right middle thyroid vein was divided between 4-0 silk ligatures. The right thyroid lobe was rotated leftward. Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified. This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed. It was sent for weight and frozen section. It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.
Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled "pre-excision." It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma. However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH. The neck was irrigated with saline and hemostasis found to be satisfactory. The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl. The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond. The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Right superior parathyroid adenoma.
PROCEDURE: Excision of right superior parathyroid adenoma.
ANESTHESIA: Local with 1% Xylocaine and anesthesia standby with sedation.
CLINICAL HISTORY: This 80-year-old woman has had some mild dementia. She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations. She was found to be hypercalcemic. Intact PTH was mildly elevated. A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.
FINDINGS AND PROCEDURE: The patient was placed on the operating table in the supine position. A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan. The electronic medical record was reviewed as was the ultrasound. The patient was sedated. A small roll was placed behind the shoulders to moderately hyperextend the neck. The head was supported in a foam head cradle. The neck and chest were prepped with chlorhexidine and isolated with sterile drapes. After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma. The larger anterior neck veins were divided between 4-0 silk ligatures. Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection. The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally. The right sternothyroid muscle was divided transversely with the cautery. The right middle thyroid vein was divided between 4-0 silk ligatures. The right thyroid lobe was rotated leftward. Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified. This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed. It was sent for weight and frozen section. It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.
Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled "pre-excision." It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma. However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH. The neck was irrigated with saline and hemostasis found to be satisfactory. The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl. The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond. The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.
Sample Name:
Pilonidal Cyst Excision
Description: Pilonidal cyst with abscess formation. Excision of infected
pilonidal cyst.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Pilonidal cyst with abscess formation.
POSTOPERATIVE DIAGNOSIS: Pilonidal cyst with abscess formation.
OPERATION: Excision of infected pilonidal cyst.
PROCEDURE: After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.
The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Pilonidal cyst with abscess formation.
OPERATION: Excision of infected pilonidal cyst.
PROCEDURE: After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.
The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.
Sample Name:
Polycythemia Rubra Vera
Description: Polycythemia rubra vera. The patient is an 83-year-old
female with a history of polycythemia vera. She comes in to clinic today for
followup. She has not required phlebotomies for several months.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Polycythemia rubra vera.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.
CURRENT MEDICATIONS: Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.
ALLERGIES: Penicillin.
REVIEW OF SYSTEMS: The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 120/56. HEART RATE: 80. TEMP: 97.3. Weight: 81.8 kg.
GEN: She looks great, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Her oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Distended. She has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
SKIN: No skin rash.
LABORATORY DATA: Hematocrit in July was 40.5. Her most recent hematocrit was 42. She again did not require phlebotomy.
ASSESSMENT/PLAN: This is an 83-year-old gentleman with polycythemia. She has not required phlebotomy for quite some time. My plan is to change her standing order for hematocrit check every two months as oppose to monthly. I will see her back in clinic in three months.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.
CURRENT MEDICATIONS: Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.
ALLERGIES: Penicillin.
REVIEW OF SYSTEMS: The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 120/56. HEART RATE: 80. TEMP: 97.3. Weight: 81.8 kg.
GEN: She looks great, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Her oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Distended. She has positive bowel sounds. No hepatosplenomegaly.
EXT: No lower extremity edema.
SKIN: No skin rash.
LABORATORY DATA: Hematocrit in July was 40.5. Her most recent hematocrit was 42. She again did not require phlebotomy.
ASSESSMENT/PLAN: This is an 83-year-old gentleman with polycythemia. She has not required phlebotomy for quite some time. My plan is to change her standing order for hematocrit check every two months as oppose to monthly. I will see her back in clinic in three months.
Sample Name:
Polycythemia Vera Followup
Description: Followup for polycythemia vera with secondary myelofibrosis.
JAK-2 positive myeloproliferative disorder. He is not a candidate for
chlorambucil or radioactive phosphorus because of his young age and the concern
for secondary malignancy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
DIAGNOSIS: Polycythemia vera with secondary myelofibrosis.
REASON FOR VISIT: Followup of the above condition.
CHIEF COMPLAINT: Left shin pain.
HISTORY OF PRESENT ILLNESS: A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.
At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.
The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.
PHYSICAL EXAMINATION:
VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.
LABORATORY DATA: CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.
ASSESSMENT AND PLAN:
1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.
2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.
3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems.
REASON FOR VISIT: Followup of the above condition.
CHIEF COMPLAINT: Left shin pain.
HISTORY OF PRESENT ILLNESS: A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.
At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.
The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.
PHYSICAL EXAMINATION:
VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.
LABORATORY DATA: CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.
ASSESSMENT AND PLAN:
1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.
2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.
3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems.
Sample Name:
Posttransplant Lymphoproliferative Disorder
Description: Posttransplant lymphoproliferative disorder, chronic renal
insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic
renal insufficiency and chemotherapy, and hypertension. The patient is here for
followup visit and chemotherapy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: The patient is here for followup visit and chemotherapy.
DIAGNOSES:
1. Posttransplant lymphoproliferative disorder.
2. Chronic renal insufficiency.
3. Squamous cell carcinoma of the skin.
4. Anemia secondary to chronic renal insufficiency and chemotherapy.
5. Hypertension.
HISTORY OF PRESENT ILLNESS: A 51-year-old white male diagnosed with PTLD in latter half of 2007. He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. He did not seek medical attention immediately. He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. He was discussed at the hematopathology conference. Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. First cycle of chemotherapy was complicated by sepsis despite growth factor support. He also appeared to have become disoriented either secondary to sepsis or steroid therapy.
The patient has received 5 cycles of chemotherapy to date. He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.
The patient is here for the sixth and final cycle of chemotherapy. He states he feels well. He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. He denies any tingling or numbness in his fingers. Review of systems is otherwise entirely negative.
Performance status on the ECOG scale is 1.
PHYSICAL EXAMINATION:
VITAL SIGNS: He is afebrile. Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. There is mild pallor noted. There is no icterus, adenopathy or petechiae noted. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. Systolic flow murmur is best heard in the pulmonary area. ABDOMEN: Soft and nontender with no organomegaly. Renal transplant is noted in the right lower quadrant with a scar present. EXTREMITIES: Reveal no edema.
LABORATORY DATA: CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.
ASSESSMENT AND PLAN:
1. Diffuse large B-cell lymphoma following transplantation. The patient is to receive his sixth and final cycle of chemotherapy today. PET scan has been ordered to be done within 2 weeks. He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.
2. Chronic renal insufficiency.
3. Anemia secondary to chronic renal failure and chemotherapy. He is to continue on his regimen of growth factor support.
4. Hypertension. This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. His CMP is pending from today.
5. Squamous cell carcinoma of the skin. The scalp is well healed. He still has an open wound on the right posterior aspect of his trunk. This has no active drainage, but it is yet to heal. This probably will heal by secondary intention once chemotherapy is finished. Prescription for prednisone as part of his chemotherapy has been given to him.
DIAGNOSES:
1. Posttransplant lymphoproliferative disorder.
2. Chronic renal insufficiency.
3. Squamous cell carcinoma of the skin.
4. Anemia secondary to chronic renal insufficiency and chemotherapy.
5. Hypertension.
HISTORY OF PRESENT ILLNESS: A 51-year-old white male diagnosed with PTLD in latter half of 2007. He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. He did not seek medical attention immediately. He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. He was discussed at the hematopathology conference. Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. First cycle of chemotherapy was complicated by sepsis despite growth factor support. He also appeared to have become disoriented either secondary to sepsis or steroid therapy.
The patient has received 5 cycles of chemotherapy to date. He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.
The patient is here for the sixth and final cycle of chemotherapy. He states he feels well. He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. He denies any tingling or numbness in his fingers. Review of systems is otherwise entirely negative.
Performance status on the ECOG scale is 1.
PHYSICAL EXAMINATION:
VITAL SIGNS: He is afebrile. Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. There is mild pallor noted. There is no icterus, adenopathy or petechiae noted. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. Systolic flow murmur is best heard in the pulmonary area. ABDOMEN: Soft and nontender with no organomegaly. Renal transplant is noted in the right lower quadrant with a scar present. EXTREMITIES: Reveal no edema.
LABORATORY DATA: CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.
ASSESSMENT AND PLAN:
1. Diffuse large B-cell lymphoma following transplantation. The patient is to receive his sixth and final cycle of chemotherapy today. PET scan has been ordered to be done within 2 weeks. He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.
2. Chronic renal insufficiency.
3. Anemia secondary to chronic renal failure and chemotherapy. He is to continue on his regimen of growth factor support.
4. Hypertension. This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. His CMP is pending from today.
5. Squamous cell carcinoma of the skin. The scalp is well healed. He still has an open wound on the right posterior aspect of his trunk. This has no active drainage, but it is yet to heal. This probably will heal by secondary intention once chemotherapy is finished. Prescription for prednisone as part of his chemotherapy has been given to him.
Sample Name:
Prostate Brachytherapy
Description: Prostate Brachytherapy - Prostate I-125 Implantation
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PROSTATE BRACHYTHERAPY - PROSTATE
I-125 IMPLANTATION
This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound will be performed and utilized in the pre-planning process. Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. Modifications will be made in real time to add or subtract needles and seeds as required. This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.
The brachytherapy must be customized to fit the individual's tumor and prostate. Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.
This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound will be performed and utilized in the pre-planning process. Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. Modifications will be made in real time to add or subtract needles and seeds as required. This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.
The brachytherapy must be customized to fit the individual's tumor and prostate. Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.
Sample Name:
Radical Mastectomy
Description: Invasive carcinoma of left breast. Left modified radical
mastectomy.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Invasive carcinoma of left breast.
POSTOPERATIVE DIAGNOSIS: Invasive carcinoma of left breast.
OPERATION PERFORMED: Left modified radical mastectomy.
ANESTHESIA: General endotracheal.
INDICATION FOR THE PROCEDURE: The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS: Invasive carcinoma of left breast.
OPERATION PERFORMED: Left modified radical mastectomy.
ANESTHESIA: General endotracheal.
INDICATION FOR THE PROCEDURE: The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.
Sample Name:
Resection of Tumor of Scalp
Description: Radical resection of tumor of the scalp, excision of tumor
from the skull with debridement of the superficial cortex with diamond bur, and
advancement flap closure.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the scalp.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS: This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma. This appears to be affixed to the underlying scalp.
PLAN: Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.
CONSENT: I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.
FINDINGS: The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull. The final periosteal margin which centrally appeared was positive for carcinoma. The final margins peripherally were all negative.
DESCRIPTION OF PROCEDURE IN DETAIL: The patient was taken to the operating room and there was placed supine on the operating room table.
General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel. The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint. Thereafter, the local anesthesia was injected into the area around the tumor. A **** type excision was planned down to the periosteum. A supraperiosteal radical resection was performed.
It was obvious that there was tumor at the deep margin, involving the periosteum. The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation. Frozen section revealed positive margins at one end of the resection. Therefore, an additional circumferential resection was performed and the final margins were all negative.
Following completion, the deep periosteal margin was resected. The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull. Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located. Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area. Therefore, no bong margin was taken. However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.
Following completion of the bony resection, the area was irrigated with copious amounts of saline. Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm. The galea was incised in multiple areas, to provide for additional mobilization of the tissue. The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.
The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.
DISPOSITION: The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.
NOTE: The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor. The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS: This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma. This appears to be affixed to the underlying scalp.
PLAN: Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.
CONSENT: I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.
FINDINGS: The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull. The final periosteal margin which centrally appeared was positive for carcinoma. The final margins peripherally were all negative.
DESCRIPTION OF PROCEDURE IN DETAIL: The patient was taken to the operating room and there was placed supine on the operating room table.
General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel. The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint. Thereafter, the local anesthesia was injected into the area around the tumor. A **** type excision was planned down to the periosteum. A supraperiosteal radical resection was performed.
It was obvious that there was tumor at the deep margin, involving the periosteum. The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation. Frozen section revealed positive margins at one end of the resection. Therefore, an additional circumferential resection was performed and the final margins were all negative.
Following completion, the deep periosteal margin was resected. The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull. Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located. Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area. Therefore, no bong margin was taken. However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.
Following completion of the bony resection, the area was irrigated with copious amounts of saline. Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm. The galea was incised in multiple areas, to provide for additional mobilization of the tissue. The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.
The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.
DISPOSITION: The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.
NOTE: The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor. The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.
Sample Name:
Sepsis - Consult
Description: Sepsis. The patient was found to have a CT scan with dilated
bladder with thick wall suggesting an outlet obstruction as well as bilateral
hydronephrosis and hydroureter.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR ADMISSION: Sepsis.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. The patient is unable to provide further history. The patient's son is at the bedside and confirmed his history. The patient was given IV antibiotics in the emergency room. He was also given some hydration.
PAST MEDICAL HISTORY:
1. History of CAD.
2. History of dementia.
3. History of CVA.
4. History of nephrolithiasis.
ALLERGIES: NONE.
MEDICATIONS:
1. Ambien.
2. Milk of magnesia.
3. Tylenol.
4. Tramadol.
5. Soma.
6. Coumadin.
7. Zoloft.
8. Allopurinol.
9. Digoxin.
10. Namenda.
11. Zocor.
12. BuSpar.
13. Detrol.
14. Coreg.
15. Colace.
16. Calcium.
17. Zantac.
18. Lasix.
19. Seroquel.
20. Aldactone.
21. Amoxicillin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives in a board and care. No tobacco, alcohol or IV drug use.
REVIEW OF SYSTEMS: As per the history of present illness, otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile. Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.
GENERAL: The patient is awake. Not oriented x3, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are dry.
NECK: Supple. No thyromegaly. No jugular venous distention.
HEART: Irregularly irregular, brady.
LUNGS: Clear to auscultation bilaterally anteriorly.
ABDOMEN: Positive normoactive bowel sounds. Soft. Tenderness in the suprapubic region without rebound.
EXTREMITIES: No clubbing, cyanosis or edema in upper and lower extremities.
NEUROLOGIC: As mentioned above. No focality is noted.
LABORATORY STUDIES: CT of the abdomen shows left inguinal hernia with greater than 10 cm of colon in sac, no SBO, dilated bladder with thick wall, possible outlet obstruction, bilateral hydronephrosis and hydroureter, and 2.7 cm right adrenal gland mass.
White count 30.8, hemoglobin 10.9, and platelet count 413. UA shows greater than 100 WBCs, greater than 100 RBCs with 500 leukocyte esterase. Sodium 149, potassium 4.1, chloride 116, CO2 19, BUN 89, and creatinine 2.1.
EKG shows atrial fibrillation at a very slow rate of 55.
PROBLEM LIST:
1. Urinary tract infection with sepsis.
2. Obstructive uropathy.
3. Dementia.
4: Atrial fibrillation.
5. Anemia.
6. Adrenal gland mass.
RECOMMENDATIONS:
1. Obtain urology consult with Dr. X.
2. Obtain renal consult Dr. Y.
3. Place the patient on Levaquin renally dosed.
4. Give one dose of gentamicin for synergy n the urine.
5. IV fluids with hypertonic-hypotonic.
6. Hold anticoagulation and put the patient on SCD and TED hose bilateral lower extremities.
7. The patient is currently in slow atrial fibrillation. Hold all rate control medications and check digoxin level.
8. Continue dementia medications.
9. PPI for PUD prophylaxis.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. The patient is unable to provide further history. The patient's son is at the bedside and confirmed his history. The patient was given IV antibiotics in the emergency room. He was also given some hydration.
PAST MEDICAL HISTORY:
1. History of CAD.
2. History of dementia.
3. History of CVA.
4. History of nephrolithiasis.
ALLERGIES: NONE.
MEDICATIONS:
1. Ambien.
2. Milk of magnesia.
3. Tylenol.
4. Tramadol.
5. Soma.
6. Coumadin.
7. Zoloft.
8. Allopurinol.
9. Digoxin.
10. Namenda.
11. Zocor.
12. BuSpar.
13. Detrol.
14. Coreg.
15. Colace.
16. Calcium.
17. Zantac.
18. Lasix.
19. Seroquel.
20. Aldactone.
21. Amoxicillin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives in a board and care. No tobacco, alcohol or IV drug use.
REVIEW OF SYSTEMS: As per the history of present illness, otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile. Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.
GENERAL: The patient is awake. Not oriented x3, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are dry.
NECK: Supple. No thyromegaly. No jugular venous distention.
HEART: Irregularly irregular, brady.
LUNGS: Clear to auscultation bilaterally anteriorly.
ABDOMEN: Positive normoactive bowel sounds. Soft. Tenderness in the suprapubic region without rebound.
EXTREMITIES: No clubbing, cyanosis or edema in upper and lower extremities.
NEUROLOGIC: As mentioned above. No focality is noted.
LABORATORY STUDIES: CT of the abdomen shows left inguinal hernia with greater than 10 cm of colon in sac, no SBO, dilated bladder with thick wall, possible outlet obstruction, bilateral hydronephrosis and hydroureter, and 2.7 cm right adrenal gland mass.
White count 30.8, hemoglobin 10.9, and platelet count 413. UA shows greater than 100 WBCs, greater than 100 RBCs with 500 leukocyte esterase. Sodium 149, potassium 4.1, chloride 116, CO2 19, BUN 89, and creatinine 2.1.
EKG shows atrial fibrillation at a very slow rate of 55.
PROBLEM LIST:
1. Urinary tract infection with sepsis.
2. Obstructive uropathy.
3. Dementia.
4: Atrial fibrillation.
5. Anemia.
6. Adrenal gland mass.
RECOMMENDATIONS:
1. Obtain urology consult with Dr. X.
2. Obtain renal consult Dr. Y.
3. Place the patient on Levaquin renally dosed.
4. Give one dose of gentamicin for synergy n the urine.
5. IV fluids with hypertonic-hypotonic.
6. Hold anticoagulation and put the patient on SCD and TED hose bilateral lower extremities.
7. The patient is currently in slow atrial fibrillation. Hold all rate control medications and check digoxin level.
8. Continue dementia medications.
9. PPI for PUD prophylaxis.
Sample Name:
Sickle Cell Anemia - ER Visit
Description: A 19-year-old known male with sickle cell anemia comes to
the emergency room on his own with 3-day history of back pain.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is a 19-year-old known male with sickle cell anemia. He
comes to the emergency room on his own with 3-day history of back pain. He is
on no medicines. He does live with a room mate. Appetite is decreased. No
diarrhea, vomiting. Voiding well. Bowels have been regular. Denies any
abdominal pain. Complains of a slight headaches, but his main concern is back
ache that extends from above the lower T-spine to the lumbosacral spine. The
patient is not sure of his immunizations. The patient does have sickle cell and
hemoglobin is followed in the Hematology Clinic.
ALLERGIES: THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.
MEDICATIONS: He was previously on folic acid. None at the present time.
PAST SURGICAL HISTORY: He has had no surgeries in the past.
FAMILY HISTORY: Positive for diabetes, hypertension and cancer.
SOCIAL HISTORY: He denies any smoking or drug usage.
PHYSICAL EXAMINATION:
VITAL SIGNS: On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute, respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.
GENERAL: He is alert, speaks in full sentences, he does not appear to be in distress.
HEENT: Normal.
NECK: Supple.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft. He has pain over the mid to lower spine.
SKIN: Color is normal.
EXTREMITIES: He moves all extremities well.
NEUROLOGIC: Age appropriate.
ER COURSE: It was indicated to the patient that I will be drawing labs and giving him IV fluids. Also that he will get morphine and Benadryl combination. The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour. CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4. Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect. The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m. He received morphine 5 mg and Benadryl 25 mg. I subsequently spoke to Dr. X and it was decided to admit the patient.
The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning. He stated that he has a job interview in the morning. The resident service did come to evaluate him. The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration. He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.
IMPRESSION: Sickle cell crisis.
DIFFERENTIAL DIAGNOSIS: Veno-occlusive crisis, and diskitis.
ALLERGIES: THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.
MEDICATIONS: He was previously on folic acid. None at the present time.
PAST SURGICAL HISTORY: He has had no surgeries in the past.
FAMILY HISTORY: Positive for diabetes, hypertension and cancer.
SOCIAL HISTORY: He denies any smoking or drug usage.
PHYSICAL EXAMINATION:
VITAL SIGNS: On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute, respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.
GENERAL: He is alert, speaks in full sentences, he does not appear to be in distress.
HEENT: Normal.
NECK: Supple.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft. He has pain over the mid to lower spine.
SKIN: Color is normal.
EXTREMITIES: He moves all extremities well.
NEUROLOGIC: Age appropriate.
ER COURSE: It was indicated to the patient that I will be drawing labs and giving him IV fluids. Also that he will get morphine and Benadryl combination. The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour. CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4. Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect. The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m. He received morphine 5 mg and Benadryl 25 mg. I subsequently spoke to Dr. X and it was decided to admit the patient.
The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning. He stated that he has a job interview in the morning. The resident service did come to evaluate him. The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration. He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.
IMPRESSION: Sickle cell crisis.
DIFFERENTIAL DIAGNOSIS: Veno-occlusive crisis, and diskitis.
Sample Name:
Symes Amputation - Hallux
Description: Excision of mass, left second toe and distal Symes
amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor.
Left hallux bone invasion of the distal phalanx.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Mass, left second toe.
2. Tumor.
3. Left hallux bone invasion of the distal phalanx.
POSTOPERATIVE DIAGNOSES:
1. Mass, left second toe.
2. Tumor.
3. Left hallux with bone invasion of the distal phalanx.
PROCEDURE PERFORMED:
1. Excision of mass, left second toe.
2. Distal Syme's amputation, left hallux with excisional biopsy.
HISTORY: This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.
PROCEDURE IN DETAIL: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.
The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.
Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
1. Mass, left second toe.
2. Tumor.
3. Left hallux bone invasion of the distal phalanx.
POSTOPERATIVE DIAGNOSES:
1. Mass, left second toe.
2. Tumor.
3. Left hallux with bone invasion of the distal phalanx.
PROCEDURE PERFORMED:
1. Excision of mass, left second toe.
2. Distal Syme's amputation, left hallux with excisional biopsy.
HISTORY: This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.
PROCEDURE IN DETAIL: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.
The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.
Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
Sample Name:
T-Cell Lymphoma Consult
Description: Newly diagnosed T-cell lymphoma. The patient reports
swelling in his left submandibular region that occurred all of a sudden about a
month and a half ago.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Newly diagnosed T-cell lymphoma.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain.
PAST MEDICAL HISTORY: Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.
FAMILY HISTORY: Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes.
SOCIAL HISTORY: The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs.
REVIEW OF SYSTEMS: As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 100/64. HEART RATE: 72. TEMP: 97. Weight: 61.4 kg.
GEN: He is a very pleasant gentleman, in no acute distress.
HEENT: He has obvious mass in submandibular region on the left. His pupils are equal, round and reactive to light. He has a nevus just below his orbit on the right hand side that has some irregularity. His pupils are equal, round and reactive to light. Sclerae anicteric. His oropharynx is clear. He has several missing teeth.
NECK: Supple. He has large palpable mass in the submandibular region and firm. He has some shotty lymphadenopathy in the posterior cervical chain bilaterally.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate, normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. He has shotty axillary adenopathy and shotty inguinal adenopathy.
EXT: Lower extremity is without edema.
His CT scan of the chest showed prominent axillary lymph nodes bilaterally, largest on the left measuring 12 x 29 mm. He has borderline enlarge right superior hilar lymph node measuring 9 x 11 mm. His lungs are benign appearing by apical pleural parenchymal scarring and very mild peri-septal emphysema. Bones shows mild disk degenerative changes in the inferior thoracic spine.
IMPRESSION:
1. Borderline enlarged right superior hilar and left axillary lymph nodes, otherwise it unremarkable CT of the chest. CT of the neck shows 4.1 x 3.0 x 3.9 cm heterogenously enhancing lesion in the left submandibular space with central necrosis. The lesion appears to be separate from the submandibular gland with displacement of the glands superiorly and posteriorly. This lesion is most suspicious for an enlarged lymph node. Also, numerous other enlarged enhancing lymph nodes in the anterior and posterior cervical chains and left supraclavicular region.
2. Prominent palatine tonsils and lingular tonsillar tissue bilaterally which may be reactive or could indicate lymphomatous involvement if the patient does have lymphoma.
3. Rim-enhancing lesions in the right parotid gland. These could be Warthin tumors or potentially necrotic intraparotid lymph nodes related to the previously described process in the neck. Pathology for fine needle aspiration of the left mandible shows an atypical cell population, the atypical cell population is difficult to define. A neoplastic process is favored. While they are fairly large, they are still within the realm of being lymphoid in nature, and they are also discohesive, which also favours of lymphoid neoplasm. He then had a biopsy of the right maxillary alveolar ridge. This was positive for high grade lymphoma most consistent with peripheral T-cell lymphoma.
ASSESSMENT/PLAN: This is a very pleasant 40-year-old gentleman with certain onset of swelling in his left neck, biopsies consistent with T-cell lymphoma. I plan at this point time is to complete the staging. He will check HTLV-1 serology. We will also send pro for blood for flow cytometry and analysis for atypical cells. We will obtain a CBC, comprehensive metabolic panel and LDH. We will also send his stool for parasites and obtain a PET CT scan. We were to preliminarily stage this he is at least stage 2 lymph nodes in the neck and the axilla seen on skin. On physical exam lymph nodes are palpable in inguinal region. He does have these symptoms with the drenching night sweats and fever. We will also check viral load and hepatitis B and C panel. The patient has not established care with infectious disease physician. We will need to reformed ID as if he true he has HIV positive, we can do some help in coordinating HIV treatment as well as treatment for what appears to be a T-cell lymphoma. Once we get these preliminary labs back then we will discuss the need for bone marrow biopsy and lumbar puncture.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain.
PAST MEDICAL HISTORY: Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.
FAMILY HISTORY: Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes.
SOCIAL HISTORY: The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs.
REVIEW OF SYSTEMS: As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative.
PHYSICAL EXAM:
VITALS: BP: 100/64. HEART RATE: 72. TEMP: 97. Weight: 61.4 kg.
GEN: He is a very pleasant gentleman, in no acute distress.
HEENT: He has obvious mass in submandibular region on the left. His pupils are equal, round and reactive to light. He has a nevus just below his orbit on the right hand side that has some irregularity. His pupils are equal, round and reactive to light. Sclerae anicteric. His oropharynx is clear. He has several missing teeth.
NECK: Supple. He has large palpable mass in the submandibular region and firm. He has some shotty lymphadenopathy in the posterior cervical chain bilaterally.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate, normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. He has shotty axillary adenopathy and shotty inguinal adenopathy.
EXT: Lower extremity is without edema.
His CT scan of the chest showed prominent axillary lymph nodes bilaterally, largest on the left measuring 12 x 29 mm. He has borderline enlarge right superior hilar lymph node measuring 9 x 11 mm. His lungs are benign appearing by apical pleural parenchymal scarring and very mild peri-septal emphysema. Bones shows mild disk degenerative changes in the inferior thoracic spine.
IMPRESSION:
1. Borderline enlarged right superior hilar and left axillary lymph nodes, otherwise it unremarkable CT of the chest. CT of the neck shows 4.1 x 3.0 x 3.9 cm heterogenously enhancing lesion in the left submandibular space with central necrosis. The lesion appears to be separate from the submandibular gland with displacement of the glands superiorly and posteriorly. This lesion is most suspicious for an enlarged lymph node. Also, numerous other enlarged enhancing lymph nodes in the anterior and posterior cervical chains and left supraclavicular region.
2. Prominent palatine tonsils and lingular tonsillar tissue bilaterally which may be reactive or could indicate lymphomatous involvement if the patient does have lymphoma.
3. Rim-enhancing lesions in the right parotid gland. These could be Warthin tumors or potentially necrotic intraparotid lymph nodes related to the previously described process in the neck. Pathology for fine needle aspiration of the left mandible shows an atypical cell population, the atypical cell population is difficult to define. A neoplastic process is favored. While they are fairly large, they are still within the realm of being lymphoid in nature, and they are also discohesive, which also favours of lymphoid neoplasm. He then had a biopsy of the right maxillary alveolar ridge. This was positive for high grade lymphoma most consistent with peripheral T-cell lymphoma.
ASSESSMENT/PLAN: This is a very pleasant 40-year-old gentleman with certain onset of swelling in his left neck, biopsies consistent with T-cell lymphoma. I plan at this point time is to complete the staging. He will check HTLV-1 serology. We will also send pro for blood for flow cytometry and analysis for atypical cells. We will obtain a CBC, comprehensive metabolic panel and LDH. We will also send his stool for parasites and obtain a PET CT scan. We were to preliminarily stage this he is at least stage 2 lymph nodes in the neck and the axilla seen on skin. On physical exam lymph nodes are palpable in inguinal region. He does have these symptoms with the drenching night sweats and fever. We will also check viral load and hepatitis B and C panel. The patient has not established care with infectious disease physician. We will need to reformed ID as if he true he has HIV positive, we can do some help in coordinating HIV treatment as well as treatment for what appears to be a T-cell lymphoma. Once we get these preliminary labs back then we will discuss the need for bone marrow biopsy and lumbar puncture.
Hematology -
Oncology
Sample Name: Thrombocytopenia - Consult
Sample Name: Thrombocytopenia - Consult
Description: Consultation for evaluation of thrombocytopenia.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Thrombocytopenia.
HISTORY OF PRESENT ILLNESS: Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. Her hemoglobin was 13.3 with white count of 11.8 at that time. Her lymphocyte count was 6.7. The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000. She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes. Platelet count was 38. Her rapid strep screen was negative but the infectious mononucleosis screen is positive. The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.
The patient gives a history of feeling generally unwell for a couple of days towards the end of May. She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that. The patient continues to have sore throat.
She denies any history of epistaxis. Denies any history of gum bleeding. The patient denies any history of petechiae. She denies any history of abnormal bleeding. Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.
The patient was accompanied by her parents.
PAST MEDICAL HISTORY: Asthma.
CURRENT MEDICATIONS: Birth control pills, Albuterol, QVAR and Rhinocort.
DRUG ALLERGIES: None.
PERSONAL HISTORY: She lives with her parents.
SOCIAL HISTORY: Denies the use of alcohol or tobacco.
FAMILY HISTORY: Noncontributory.
OCCUPATION: The patient is currently in school.
REVIEW OF SYSTEMS:
Constitutional: The history of fever about 2 weeks ago.
HEENT: Complains of some difficulty in swallowing.
Cardiovascular: Negative.
Respiratory: Negative.
Gastrointestinal: No nausea, vomiting, or abdominal pain.
Genitourinary: No dysuria or hematuria.
Musculoskeletal: Complains of generalized body aches.
Psychiatric: No anxiety or depression.
Neurologic: Complains of episode of headaches about 2-3 weeks ago.
PHYSICAL EXAMINATION: She was not in any distress. She appears her stated age. Temperature 97.9. Pulse 84. Blood pressure was 110/60. Weighs 162 pounds. Height of 61 inches. Lungs - Normal effort. Clear. No wheezing. Heart - Rate and rhythm regular. No S3, no S4. Abdomen - Soft. Bowel sounds are present. No palpable hepatosplenomegaly. Extremities - Without any edema, pallor, or cyanosis. Neurological: Alert and oriented x 3. No focal deficit. Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla. Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.
DIAGNOSTIC DATA: The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.
IMPRESSION: ITP, the patient has a normal platelet count.
PLAN:
1. I had a long discussion with family regarding the treatment of ITP. In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.
2. An ultrasound of the abdomen will be performed tomorrow.
3. I have given her a requisition to obtain some blood work tomorrow.
HISTORY OF PRESENT ILLNESS: Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. Her hemoglobin was 13.3 with white count of 11.8 at that time. Her lymphocyte count was 6.7. The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000. She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes. Platelet count was 38. Her rapid strep screen was negative but the infectious mononucleosis screen is positive. The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.
The patient gives a history of feeling generally unwell for a couple of days towards the end of May. She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that. The patient continues to have sore throat.
She denies any history of epistaxis. Denies any history of gum bleeding. The patient denies any history of petechiae. She denies any history of abnormal bleeding. Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.
The patient was accompanied by her parents.
PAST MEDICAL HISTORY: Asthma.
CURRENT MEDICATIONS: Birth control pills, Albuterol, QVAR and Rhinocort.
DRUG ALLERGIES: None.
PERSONAL HISTORY: She lives with her parents.
SOCIAL HISTORY: Denies the use of alcohol or tobacco.
FAMILY HISTORY: Noncontributory.
OCCUPATION: The patient is currently in school.
REVIEW OF SYSTEMS:
Constitutional: The history of fever about 2 weeks ago.
HEENT: Complains of some difficulty in swallowing.
Cardiovascular: Negative.
Respiratory: Negative.
Gastrointestinal: No nausea, vomiting, or abdominal pain.
Genitourinary: No dysuria or hematuria.
Musculoskeletal: Complains of generalized body aches.
Psychiatric: No anxiety or depression.
Neurologic: Complains of episode of headaches about 2-3 weeks ago.
PHYSICAL EXAMINATION: She was not in any distress. She appears her stated age. Temperature 97.9. Pulse 84. Blood pressure was 110/60. Weighs 162 pounds. Height of 61 inches. Lungs - Normal effort. Clear. No wheezing. Heart - Rate and rhythm regular. No S3, no S4. Abdomen - Soft. Bowel sounds are present. No palpable hepatosplenomegaly. Extremities - Without any edema, pallor, or cyanosis. Neurological: Alert and oriented x 3. No focal deficit. Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla. Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.
DIAGNOSTIC DATA: The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.
IMPRESSION: ITP, the patient has a normal platelet count.
PLAN:
1. I had a long discussion with family regarding the treatment of ITP. In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.
2. An ultrasound of the abdomen will be performed tomorrow.
3. I have given her a requisition to obtain some blood work tomorrow.
Sample Name:
Thrombocytopenia - SOAP Note
Description: Patient with immune thrombocytopenia
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
SUBJECTIVE: I am following the patient today for immune
thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after
learning of that result, I increased her prednisone to 60 mg a day. Repeat on
01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I
have spoken with her hematologist who recommends at this point we decrease her
prednisone to 40 mg for 3 days and then go down to 20 mg a day. The patient had
been on 20 mg every other day at least for a while, and her platelets hovered
at least above 20 or so.
PHYSICAL EXAMINATION: Vitals: As in chart. The patient is alert, pleasant, and cooperative. She is in no apparent distress. The petechial areas on her legs have resolved.
ASSESSMENT AND PLAN: Patient with improvement of her platelet count on burst of prednisone. We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. Basically thereafter, over time, I may try to sneak it back a little bit further. She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D. We will arrange to have a CBC drawn weekly.
PHYSICAL EXAMINATION: Vitals: As in chart. The patient is alert, pleasant, and cooperative. She is in no apparent distress. The petechial areas on her legs have resolved.
ASSESSMENT AND PLAN: Patient with improvement of her platelet count on burst of prednisone. We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. Basically thereafter, over time, I may try to sneak it back a little bit further. She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D. We will arrange to have a CBC drawn weekly.
Sample Name:
Thrombocytosis Followup
Description: Essential thrombocytosis. He underwent a bone marrow biopsy,
which showed essential thrombocytosis. His CBC has been very stable.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Essential thrombocytosis.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis. He was first diagnosed when he first saw a hematologist on 07/09/07. At that time, his platelet count was 1,240,000. He was initially started on Hydrea 1000 mg q.d. On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis. He was positive for the JAK-2 mutation. On 11/06/07, his platelets were noted to be 766,000. His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days. He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.
Overall, he is doing well. He has a good energy level, and his ECOG performance status is 0. He denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week, Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. He is status post an appendectomy.
2. Status post a tonsillectomy and adenoidectomy.
3. Status post bilateral cataract surgery.
4. BPH.
SOCIAL HISTORY: He has a history of tobacco use, which he quit at the age of 37. He has one alcoholic drink per day. He is married. He is a retired lab manager.
FAMILY HISTORY: There is no history of solid tumor or hematologic malignancies in his family.
PHYSICAL EXAM:
VIT: Height 181 cm, weight 72 kg, blood pressure 116/64, pulse 62, and temperature is 96.7.
GEN: He is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Essential thrombocytosis. Over time, his CBC has been very stable. His most recent CBC shows a white blood cell count of 6.0 with hemoglobin of 13.7 and platelet count of 381,000. His MCV is elevated at 120.8; however, this is a known side effect of hydroxyurea. I will plan on checking his CBC again in three months and then see him again in six months with a CBC.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis. He was first diagnosed when he first saw a hematologist on 07/09/07. At that time, his platelet count was 1,240,000. He was initially started on Hydrea 1000 mg q.d. On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis. He was positive for the JAK-2 mutation. On 11/06/07, his platelets were noted to be 766,000. His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days. He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.
Overall, he is doing well. He has a good energy level, and his ECOG performance status is 0. He denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.
CURRENT MEDICATIONS: Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week, Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As per the HPI, otherwise negative.
PAST MEDICAL HISTORY:
1. He is status post an appendectomy.
2. Status post a tonsillectomy and adenoidectomy.
3. Status post bilateral cataract surgery.
4. BPH.
SOCIAL HISTORY: He has a history of tobacco use, which he quit at the age of 37. He has one alcoholic drink per day. He is married. He is a retired lab manager.
FAMILY HISTORY: There is no history of solid tumor or hematologic malignancies in his family.
PHYSICAL EXAM:
VIT: Height 181 cm, weight 72 kg, blood pressure 116/64, pulse 62, and temperature is 96.7.
GEN: He is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
EYES: Anicteric.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
EXT: Reveal no edema.
ASSESSMENT/PLAN: Essential thrombocytosis. Over time, his CBC has been very stable. His most recent CBC shows a white blood cell count of 6.0 with hemoglobin of 13.7 and platelet count of 381,000. His MCV is elevated at 120.8; however, this is a known side effect of hydroxyurea. I will plan on checking his CBC again in three months and then see him again in six months with a CBC.
Sample Name:
Thyroid Mass Consult
Description: Thyroid mass diagnosed as papillary carcinoma. The patient
is a 16-year-old young lady with a history of thyroid mass that is now biopsy
proven as papillary. The pattern of miliary metastatic lesions in the chest is
consistent with this diagnosis.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Thyroid mass diagnosed as papillary carcinoma.
HISTORY OF PRESENT ILLNESS: The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy. The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004. An ultrasound examination had reportedly been done in the past and the mass is being observed. When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there. The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma. The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction. She has no weight changes consistent with either hyper or hypothyroidism. There is no family history of thyroid cancer in her family. She has no notable discomfort with this lesion. There have been no skin changes. Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.
PAST MEDICAL HISTORY: Essentially unremarkable. The patient has never been hospitalized in the past for any major illnesses. She has had no prior surgical procedures.
IMMUNIZATIONS: Current and up to date.
ALLERGIES: She has no known drug allergies.
CURRENT MEDICATIONS: Currently taking no routine medications. She describes her pain level currently as zero.
FAMILY HISTORY: There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter. This was done in Tijuana. His mom is from central portion of Mexico. There is no family history of multiple endocrine neoplasia syndromes.
SOCIAL HISTORY: The patient is a junior at Hoover High School. She lives with her mom in Fresno.
REVIEW OF SYSTEMS: A careful 12-system review was completely normal except for the problems related to the thyroid mass.
PHYSICAL EXAMINATION:
GENERAL: The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress. She was alert and oriented x3 and had an appropriate affect.
HEENT: The head and neck examination is most significant. There is mild amount of facial acne. The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.
NECK: There is a slightly visible midline bulge in the region of the thyroid isthmus. A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid. This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine. There are some shotty adenopathy in the area. No supraclavicular nodes were noted.
CHEST: Excursions are symmetric with good air entry.
LUNGS: Clear.
CARDIOVASCULAR: Normal. There is no tachycardia or murmur noted.
ABDOMEN: Benign.
EXTREMITIES: Extremities are anatomically correct with full range of motion.
GENITOURINARY: External genitourinary exam was deferred at this time and can be performed later during anesthesia. This is same as too for her rectal examination.
SKIN: There is no acute rash, purpura, or petechiae.
NEUROLOGIC: Normal and no focal deficits. Her voice is strong and clear. There is no evidence of dysphonia or vocal cord malfunction.
DIAGNOSTIC STUDIES: I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range. T4 and TSH levels were recorded as normal. Free thyroxine was normal, and the serum pregnancy test was negative. There was no level of thyroglobulin recorded on this. A urinalysis and comprehensive metabolic panel was unremarkable. A chest x-ray was obtained, which I personally reviewed. There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.
IMPRESSION/PLAN: The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease. I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease. During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy. We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation. We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well. I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them. I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit. This will have some impact on the postoperative adjunctive therapy. The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case. I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity. All of the family's questions have been answered. This is a very anxious and anxiety provoking time in the family. I have made every effort to get the patient under schedule within the next 48 hours to have this operation done. We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy. The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004. An ultrasound examination had reportedly been done in the past and the mass is being observed. When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there. The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma. The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction. She has no weight changes consistent with either hyper or hypothyroidism. There is no family history of thyroid cancer in her family. She has no notable discomfort with this lesion. There have been no skin changes. Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.
PAST MEDICAL HISTORY: Essentially unremarkable. The patient has never been hospitalized in the past for any major illnesses. She has had no prior surgical procedures.
IMMUNIZATIONS: Current and up to date.
ALLERGIES: She has no known drug allergies.
CURRENT MEDICATIONS: Currently taking no routine medications. She describes her pain level currently as zero.
FAMILY HISTORY: There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter. This was done in Tijuana. His mom is from central portion of Mexico. There is no family history of multiple endocrine neoplasia syndromes.
SOCIAL HISTORY: The patient is a junior at Hoover High School. She lives with her mom in Fresno.
REVIEW OF SYSTEMS: A careful 12-system review was completely normal except for the problems related to the thyroid mass.
PHYSICAL EXAMINATION:
GENERAL: The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress. She was alert and oriented x3 and had an appropriate affect.
HEENT: The head and neck examination is most significant. There is mild amount of facial acne. The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.
NECK: There is a slightly visible midline bulge in the region of the thyroid isthmus. A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid. This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine. There are some shotty adenopathy in the area. No supraclavicular nodes were noted.
CHEST: Excursions are symmetric with good air entry.
LUNGS: Clear.
CARDIOVASCULAR: Normal. There is no tachycardia or murmur noted.
ABDOMEN: Benign.
EXTREMITIES: Extremities are anatomically correct with full range of motion.
GENITOURINARY: External genitourinary exam was deferred at this time and can be performed later during anesthesia. This is same as too for her rectal examination.
SKIN: There is no acute rash, purpura, or petechiae.
NEUROLOGIC: Normal and no focal deficits. Her voice is strong and clear. There is no evidence of dysphonia or vocal cord malfunction.
DIAGNOSTIC STUDIES: I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range. T4 and TSH levels were recorded as normal. Free thyroxine was normal, and the serum pregnancy test was negative. There was no level of thyroglobulin recorded on this. A urinalysis and comprehensive metabolic panel was unremarkable. A chest x-ray was obtained, which I personally reviewed. There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.
IMPRESSION/PLAN: The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease. I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease. During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy. We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation. We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well. I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them. I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit. This will have some impact on the postoperative adjunctive therapy. The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case. I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity. All of the family's questions have been answered. This is a very anxious and anxiety provoking time in the family. I have made every effort to get the patient under schedule within the next 48 hours to have this operation done. We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.
Sample Name:
Tongue Lesion Biopsy
Description: Excisional biopsy with primary closure of a 4 mm right
lateral base of tongue lesion. Right lateral base of tongue lesion, probable
cancer.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right lateral base of tongue lesion, probable cancer.
POSTOPERATIVE DIAGNOSIS: Right lateral base of tongue lesion, probable cancer.
PROCEDURE PERFORMED: Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.
ANESTHESIA: General.
FINDINGS: An ulceration in the right lateral base of tongue region. This was completely excised.
ESTIMATED BLOOD LOSS: Less than 5 mL.
FLUIDS: Crystalloid only.
COMPLICATIONS: None.
DRAINS: None.
CONDITION: Stable.
PROCEDURE: The patient placed supine in position under general anesthesia. First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated. The lesion in the tongue could be seen. Then, it was injected with 1% lidocaine and 1:100,00 epinephrine. After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total. Suction cautery was used for hemostasis. Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.
POSTOPERATIVE DIAGNOSIS: Right lateral base of tongue lesion, probable cancer.
PROCEDURE PERFORMED: Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.
ANESTHESIA: General.
FINDINGS: An ulceration in the right lateral base of tongue region. This was completely excised.
ESTIMATED BLOOD LOSS: Less than 5 mL.
FLUIDS: Crystalloid only.
COMPLICATIONS: None.
DRAINS: None.
CONDITION: Stable.
PROCEDURE: The patient placed supine in position under general anesthesia. First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated. The lesion in the tongue could be seen. Then, it was injected with 1% lidocaine and 1:100,00 epinephrine. After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total. Suction cautery was used for hemostasis. Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.
Sample Name:
True Cut Needle Biopsy - Breast
Description: True cut needle biopsy of the breast. This 65-year-old
female on exam was noted to have dimpling and puckering of the skin associated
with nipple discharge. On exam, she has a noticeable carcinoma of the left
breast with dimpling, puckering, and erosion through the skin.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Carcinoma of the left breast.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the left breast.
PROCEDURE PERFORMED: True cut needle biopsy of the breast.
GROSS FINDINGS: This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.
PROCEDURE: The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the left breast.
PROCEDURE PERFORMED: True cut needle biopsy of the breast.
GROSS FINDINGS: This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin. At this time, a true cut needle biopsy was performed.
PROCEDURE: The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion. The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine. Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion. Hemostasis was controlled with pressure. The patient tolerated the procedure well, pending the results of biopsy.
Sample Name:
Uterine Papillary Serous Carcinoma
Description: The patient is a 67-year-old white female with a history of
uterine papillary serous carcinoma who is status post 6 cycles of carboplatin
and Taxol, is here today for followup.
(Medical Transcription Sample Report)
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old white female with a history of
uterine papillary serous carcinoma who is status post 6 cycles of carboplatin
and Taxol, is here today for followup. Her last cycle of chemotherapy was
finished on 01/18/08, and she complains about some numbness in her right upper
extremity. This has not gotten worse recently and there is no numbness in her
toes. She denies any tingling or burning.
REVIEW OF SYSTEMS: Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria. The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg. GENERAL: She is a middle-aged white female, not in any distress. HEENT: No lymphadenopathy or mucositis. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: No focal deficits noted. PELVIC: Normal-appearing external genitalia. Vaginal vault with no masses or bleeding.
LABORATORY DATA: None today.
RADIOLOGIC DATA: CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff. No local or distant metastasis. Right probably chronic gonadal vein thrombosis.
ASSESSMENT: This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy. She is doing well with no evidence of disease clinically or radiologically.
PLAN:
1. Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.
2. The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.
3. The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.
4. The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.
REVIEW OF SYSTEMS: Negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria. The patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg. GENERAL: She is a middle-aged white female, not in any distress. HEENT: No lymphadenopathy or mucositis. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: No focal deficits noted. PELVIC: Normal-appearing external genitalia. Vaginal vault with no masses or bleeding.
LABORATORY DATA: None today.
RADIOLOGIC DATA: CT of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff. No local or distant metastasis. Right probably chronic gonadal vein thrombosis.
ASSESSMENT: This is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and Taxol chemotherapy. She is doing well with no evidence of disease clinically or radiologically.
PLAN:
1. Plan to follow her every 3 months and CT scans every 6 months for the first 2 years.
2. The patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.
3. The patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.
4. The patient was advised about doing Kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.
